.  HX64055582 
RD35  Ei8  Surgical  diagnosis, 


RECAP 


RJ^^s 


tiB 


(Sift  nf  ir.  Snsppii  A.  llakr 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicaldiagnosiOOeise 


Surgical  Diagnosis 


BY 

DANIEL   N.  EISENDRATH,  A.B.,  M.D. 

ADJUNCT    PROFESSOR    OF    SURGERY    IN    THE    MEDICAL    DEPARTMENT    OF    THE    UNIVERSITY    OF 

ILLINOIS    (COLLEGE   OF    PHYSICIANS   AND  SURGEONS);    ATTENDING  SURGEON   TO  THE 

MICHAEL    REESE    AND    COOK    COUNTY    HOSPITALS,    CHICAGO 


WITH  FOUR  HUNDRED  AND  EIGHTY-TWO   ORIGINAL 
ILLUSTRATIONS,    FIFTEEN    OF     THEM     IN     COLORS 


PHILADELPHIA  AND   LONDON 

W:  B.   SAUNDERS    COMPANY 

1907 


Copyright,  1907,  by  W.  B.  Saunders  Company 


PRINTED    IX    PHILADELPHIA 


PREFACE. 


A  recognition  of  the  necessity  of  making  a  correct  diagnosis  before 
instituting  treatment  has  prompted  me  to  write  this  treatise.  I  have 
omitted  the  diagnosis  of  affections  of  the  eye,  ear,  nose,  throat,  and  skin, 
since  these  are  so  fully  considered  in  the  special  treatises  upon  these  sub- 
jects. The  only  exceptions  are  the  intracranial  complications  of  middle 
ear  and  mastoid  disease  and  those  affections  of  the  upper  respiratory 
tract  which  require  major  surgical  intervention. 

The  question  of  diagnosis  has  been  approached  chiefly  from  the 
clinical  standpoint.  An  attempt  has  been  made  to  group  injuries  and 
diseases  in  the  manner  in  which  the  surgeon  or  general  practitioner  must 
consider  them  when  he  examines  a  patient  for  the  purpose  of  making  a 
diagnosis.  Thus,  in  the  chapter  upon  injuries  of  the  head,  the  various 
traumatic  lesions  of  the  scalp,  skull,  and  brain  are  considered  together. 
In  the  chapter  upon  the  abdomen  the  injuries  of  all  of  the  abdominal  vis- 
cera are  taken  up  in  a  similar  manner. 

The  division  of  diseases  of  the  abdomen  into  acute  abdominal  affec- 
tions, abdominal  tumors,  and  a  further  description  of  the  remaining 
surgical  conditions  of  the  abdominal  viscera,  may  occasion  some  criticism. 
In  making  such  an  apparently  arbitrary  classification  I  have  had  in  mind 
the  clinical  picture  as  one  encounters  it  at  the  bedside.  Although  such 
divisions  are  not  appropriate  for  a  text-book  which  includes  pathology 
and  treatment,  they  seem  most  practical  for  a  book  limited  to  diagnosis. 

The  same  principle  has  been  applied  throughout.  The  importance 
of  differentiation  of  affections  which  simulate  each  other  has  been  con- 
stantly borne  in  mind,  repetition  being  avoided  as  much  as  possible. 
The  necessity  of  making  a  diagnosis  at  an  early  period  for  the  purpose 
of  instituting  prompt  surgical  intervention,  is  frequently  referred  to. 
Much  attention  has  been  paid  to  the  description  of  methods  of  examina- 
tion, and  this  has  been  aided  wherever  possible  by  illustrations. 

Being  ^  strong  advocate  of  the  teaching  of  surgery  by  the  education 
of  the  eye,  I  have  introduced  a  large  number  of  original  illustrations  of 
clinical  cases  and  specimens.  I  am  indebted  to  my  colleagues  upon  the 
staffs  of  the  Cook  County  and  Michael  Reese  Hospitals  for  the  privilege 

9 


lO  PREFACE. 

of  photographing  many  of  their  patients.  I  desire  to  thank  Drs.  I\I.  L. 
Blatt  and  F.  Baumann  for  valuable  suggestions.  The  section  upon 
methods  of  blood  examination  was  written  by  Dr.  D.  L.  Schram.  The 
section  upon  cystoscopy  and  ureteral  catheterization  was  written  by  Dr. 
Gustav  Kolischer. 

Daniel  N.  Eisendrath. 

April,  1907. 


CONTENTS 


CHAPTER  I.  PAGE 

Surgical  Affections  of  the  Head 17 

Injuries  of  the  Scalp,  Skull,  and  Brain 17 

Injuries  of  the  Scalp 17 

Fractures  of  the  Skull 22 

Concussion  of  the  Brain , 35 

Compression  of  the  Brain 36 

Cerebral  Contusion  or  Laceration 42 

Cerebral  Localization 44 

Intracranial  Hemorrhage 48 

Differential  Diagnosis  of  Injuries  of  the  Brain 54 

Pachymeningitis  Hsemorrhagica  Interna 55 

Intracranial  Suppuration  Following  Injuries 55 

Contusions  of  the  Cranial  Bones 61 

Hernia  Cerebri 62 

Traumatic  Epilepsy 62 

Mental  Conditions  Following  Cranial  Injury 64 

Diseases  of  the  Scalp,  Skull,  and  Brain 65 

Diseases  of  the  Scalp 65 

Non-traumatic  Surgical  Diseases  of  the  Brain  and  its  Envelopes 73 

Intracranial  Complications  of  Middle  Ear  and  Mastoid  Suppuration 80 

Injuries  and  Diseases  of  the  Face r 86 

Injuries  of  the  Soft  Parts  of  the  Face 86 

Injuries  of  the  Bones  of  the  Face 87 

Diseases  of  the  Soft  Parts  of  the  Face 9^ 

Diseases  of  the  Mouth  and  Palate 103 

The  Lips 104 

Diseases  of  the  Jaws 108 

Tumors 108 

Infections 1^7 

Diseases  of  the  Temporo-maxillary  Joint 122 

Diseases  of  the  Mouth 123 

Stomatitis 123 

Syphilis ^-4 

The  Diagnosis  of  Conditions  at  the  Floor  of  the  Mouth 124 

Tumors  of  the  Inside  of  the  Cheeks 127 

Tumors  of  the  Palate ^27 

The  Tongue 127 

Affections  of  the  Salivary  Glands 138 

CHAPTER  II. 

Surgical  Affections  of  the  Neck i47 

Congenital  and  Acquired  Malformations i47 


12  CONTENTS. 

PAGE 

Injuries  of  the  Neck 152 

Foreign  Bodies  in  the  Air  Passages 156 

Inflammatory  Processes 157 

Infection  of  the  Superficial  Structures  of  the;  Neck 160 

Affections  of  the  L}Tnph-nodes  of  the  Neck 162 

Tumors  of  the  Neck 172 

Cystic  Tumors 174 

Solid  Tumors 178 

Non-malignant  Goiter 185 

Malignant  Goiter 187 

Thyroiditis 188 

Exophthalmic  Goiter 189 

Edema  of  the  Glottis 190 

Papilloma  of  the  Lar\-nx 190 

Carcinoma  of  the  Lar}mx 191 

CHAPTER  III. 

Thorax 193 

Injuries  of  the  Bony  Walls  of  the  Thorax 193 

Fractures  of  the  Ribs 193 

Fractures  of  the  Costal  Cartilages 194 

Fractures  of  the  Sternum 194 

Injuries  of  the  Thoracic  Viscera 195 

Non-penetrating  or  Subcutaneous 195 

Penetrating  Injuries  of  the  Thorax  Proper 199 

Acute  and  Chronic  Infiammators'  Processes  of  the  Thoracic  Wall 201 

Of  the  Skin  and  Subcutaneous  Tissues 201 

Affections  of  the  Bony  Thorax 202 

Tumors  of  the  Chest  Wall 206 

Empyema 208 

Tumors  of  the  Pleura 212 

Pulmonary  Abscess,  Gangrene,  and  Bronchiectasis 213 

Echinococcus  of  the  Lungs 216 

Actinomycosis  of  the  Lungs  and  Pleura 216 

Tvunors  of  the  Lungs 217 

Suppurative  Pericarditis 217 

Affections  of  the  Mediastinum 218 

Inflammator}'  Processes 218 

Tumors 219 

Foreign  Bodies  in  the  Air  Passages •. 220 

Diseases  of  the  Breast 221 

Inflammatory  Processes 221 

Tuberculosis 225 

Hypertrophy 227 

Neoplasms 227 

CHAPTER  IV. 

Abdomen- 231 

Affections  of  the  Abdominal  Wall 231 

Inflammatory  Processes 231 

Tumors ■  -  -  233 

Congenital  Conditions 235 


CONTENTS. 


13 


PAGE 

Abscesses  'Discharging  through  Umbilicus 236 

Tumors  of  the  Umbilicus 236 

Injuries  of  the  Abdominal  Walls  and  Viscera 237 

Acute  Abdominal  Affections 245 

Acute  Cholecystitis 246 

Hepatic  Infections 248 

Primary  Forms  of  Peritonitis 250 

Renal  Infection 251 

Subphrenic  Abscess 253 

Suppurating  Echinococcus  Cysts  of  the  Liver 254 

Pericolitis  Sinistra 255 

Multiple  Abscesses  of  the  Omentum 255 

Appendicitis 256 

Gallstone  Colic 264 

Perforations  of  Ulcers  of  the  Stomach  or  Duodenum 266 

Acute  Pancreatitis 270 

Renal  Colic 270 

Dietl's  Crises 271 

Embolism  and  Thrombosis  of  the  Mesenteric  Vessels 272 

Torsion  of  the  Pedicles  of  Ovarian  and  Uterine  Tumors 273 

Torsion  of  the  Spermatic  Cord 274 

Visceral  Crises 274 

Angina  Sclerotica  Abdominis 276 

Referred  Pain  from  Spinal  and  Thoracic  Conditions 276 

Inflammation  of  the  Intraabdominal  Portion  of  the  Vas  Deferens 276 

Acute  Intestinal  Obstruction 277 

Ruptured  Extrauterine  Pregnancy 284 

Abdominal  Tumors 285 

Tumors  of  the  Stomach 289 

Tumors  of  the  Liver 291 

Tumors  of  the  Gallbladder 297 

Tumors  of  the  Pancreas 299 

Tumors  of  the  Spleen 304 

Tumors  of  the  Intestines 307 

Tumors  of  the  Peritoneum  and  Mesentery 310 

Tumors  of  the  Kidney ■ 311 

Ascites 318 

Tumors  due  to  Inflammatory  Exudates  or  to  Tuberculous  Peritonitis 320 

Tumors  due  to  Aneurysms  of  the  Abdominal  Aorta  or  its  Branches 321 

Tumors  of  the  Abdomen  having  their  Origin  in  the  Pelvic  Viscera  or  Bones.   323 

Diseases  of  the  Esophagus 324 

Stricture 324 

Diverticula 329 

Idiopathic  Dilatation .- 330 

Foregin  Bodies 330 

Other  Abdominal  Conditions 331 

Surgical  Diseases  of  the  Stomach, 331 

Gallstones 337 

Appendicitis  (Chronic) 34° 

Chronic  Intestinal  Obstruction 341 

Tuberculous  Peritonitis 343 

The  Rectum 345 


14  CONTENTS. 

PAGE 

Methods  of  Examination 345 

Congenital  Malformations 346 

Injuries 347 

Foreign  Bodies 348 

Inflammatory  Processes 349 

Hemorrhoids 355 

Prolapse 356 

Strictures 357 

Neoplasms 359 

Renal  and  Vesical  Lesions 361 

Older  and  Newer  Methods  of  Diagnosis 361 

Pyelitis 362 

Tuberculosis  of  the  Kidney 363 

Diagnosis  of  Renal  Calculi 365 

The  Bladder 371 

Congenital  Malformations 371 

Wounds 372 

Inflammation 372 

Tuberculosis 374 

Calculi 375 

Tumors 376 

Affections  of  the  Prostate 377 

Enlargement 377 

Injuries  and  Diseases  of  the  Urethra  and  Penis 379 

Congenital  Malformations 379 

Contusion  and  Rupture  of  the  Urethra 380 

Localization  of  Pus  in  the  Lower  Portion  of  the  Male  Genito-urinary  Tract. . .  381 

Phimosis 385 

Paraphimosis 385 

Balanitis 385 

Epithelioma  of  the  Penis 386 

The  Testes 387 

Abnormalities  in  Development 387 

Imperfect  Descent  and  its  Complications 388 

Infections  of  the  Male  Reproductive  Organs 391 

Traumatic  Affections 393 

Tuberculosis 393 

Syphilis 398 

Tumors  of  the  Testis  and  Epididymis 399 

Spermatocele 399 

Neoplasms  of  the  Testis 399 

Hernia 401 

Inguinal  Hernia 404 

Femoral  Hernia 414 

Umbilical  Hernia 417 

Ventral  Hernia 420 

Rarer  Forms  of  Hernia 42 1 

CHAPTER  V. 

The  Extremities 422 

Injuries  of  the  Soft  Tissues,  Bones,  and  Joints, 422 

Injuries  of  Muscles,  Tendons,  and  Tendon-sheaths 424 


CONTENTS.  15 

PAGE 

Injuries  of  Blood-vessels 429 

Injuries  of  Nerves 433 

Injuries  of  Individual  Nerves 435 

General  Considerations  upon  Injuries  of  the  Bones 43^ 

General  Considerations  upon  Injuries  of  the  Joints 45° 

General  Considerations  upon  Dislocations 45^ 

Special  Fractures  and  Dislocations 461 

Complications  of  Injuries 5^5 

Shock  and  Hemorrhage 5^5 

Traumatic  Delirium  and  Delirium  Tremens 528 

Infective  Complications  of  Wounds 529 

Surgical  Diseases  of  the  Extremities 544 

Affections  of  the  Skin  and  Subcutaneous  Tissues 544 

Surgical  Diseases  of  the  Skin 554 

Diseases  of  the  Arteries 557 

Diseases  of  the  Veins 5^^ 

Diseases  of  the  Lymph-vessels 5^3 

Diseases  of  the  Lymph-nodes 5^5 

Diseases  of  the  Bursae 5^^ 

Diseases  of  the  Tendons  and  Tendon-sheaths 567 

Diseases  of  Muscles 57° 

Diseases  of  the  Fascije 573 

Diseases  of  the  Nerves 573 

Diseases  of  the  Bones 575 

Diseases  of  the  Joints  in  General 601 

Diseases  of  the  Individual  Joints 627 

Diseases  of  the  Knee-joint 639 

Diseases  of  the  Ankle-joint 644 

Deformities 646 

CHAPTER  VI. 

Diseases  and  Injuries  of  the  Spine 662 

Spina  Bifida 662 

Injuries  of  the  Spine 664 

Spinal  Localization 666 

Diseases  of  the  Spine 684 

Tuberculous  Spondylitis  (Pott's  Disease) 684 

Scoliosis  (Lateral  Curvature  of  the  Spine) 690 

Arthritis  Deformans  (Spondylitis  Deformans) 691 

Acute  Osteomyelitis 69 1 

Typhoid  Spine 692 

Hysterical  Spine 692 

Tumors  of  the  Spine  and  Spinal  Cord 692 

Sacrococcygeal  Tumors 695 

CHAPTER  VII. 

Postoperative  Complications 696 

Hemorrhage 696 

Shock  and  Collapse , 699 

Infection 700 

Pulmonary  Complications 701 


l6  CONTENTS. 

PAGE 

Cardiac  Complications 702 

Hepatic  Complications 703 

Gastric  Complications 704 

Postoperative  Ileus 707 

Postoperative  Peritonitis 708 

Renal  Complications 709 

Circulatory  Complications 710 

Miscellaneous  Complications 711 

Diabetic  Complications 712 

Postoperative  Parotitis 713 

Status  Thymicus 713 

Acute  Thyroidism 714 

Postoperative  Hysteria 714 

CHAPTER  VIII. 

Methods  of  Examination 715 

Examination  of  the  Blood  in  Surgical  Cases 715 

Differential  Leukocyte-count 715 

Opsonins  and  the  Opsonic  Index 716 

Leukopenia,  Leukocytosis,  and  Hyperleukocytosis 720 

Value  of  the  Differential  Leukocyte-count 725 

Pernicious  Anemia 728 

Leukemia 728 

Estimation  of  Blood-pressure  in  Surgical  Cases ' 729 

Cytddiagnosis : 731 

Examination  of  the  Sputum,  Stomach  Contents,  Urine,  and  Feces 732 

The  Newer  Methods  of  Diagnosis  of  Renal  Lesions 732 


Index 75: 


Surgical  Diagnosis. 


CHAPTER  I. 

SURGICAL  AFFECTIONS  OF  THE  HEAD. 

Injuries  of  the  Scalp,  Skull,  and  Brain. 

For  clinical  purposes  the  scalp  can  be  considered  as  composed  of 
three  layers  (Fig.  i),  viz.,  the  outer  or  cutaneo-aponeurotic,  the  middle 
or  subaponeurotic,  and  the  inner  or  pericranial.  In  infants  the  last- 
named  layer  or  pericranium  is  loosely  attached  to  the  skull,  except 
along  the  sutures,  while  in  the  adult  it  is  so  firmly  attached  over  the 
entire  vertex  that  it  can  be  torn  off  only  with  difficulty. 


INJURIES  OF  THE  SCALP. 

These  occur  either  in  the  form  (a)  of  penetrating,  i.  e.,  lacerated, 
incised,  or  punctured  wounds,  which  may  penetrate  one  or  more  of 
the  layers,  or  (b)  appear  as  contusions  with  swelling  of  these  layers 
caused  by  extravasation  of  blood,  or  (c)  the  two  forms  may  be  combined. 

Penetrating  Wounds. — ^The  diagnosis  of  these  is  readily  made  by 
inspection,  which  should  be  preceded  by  shaving  the  scalp  for  a  dis- 
tance of  at  least  three  inches  from  the  edges  of  the  wound.  The  chief 
point  of  interest  is  to  ascertain  whether  they  simply  extend  (a)  through 
the  skin  and  subcutaneous  tissue,  or  (b)  through  the  aponeurosis. 
Wounds  of  the  former  class  never  gape,  while  in  those  of  the  latter 
class  the  edges  separate.  Retraction  of  these  edges  will  enable  one  to 
determine  whether  the  wound  also  involves  the  pericranium  and  skull. 
It  cannot  be  too  strongly  emphasized  that  the  greatest  care  should 
be  exercised  to  render  aseptic  not  only  the  scalp  itself,  but  also  the  hands 
of  the  examiner  and  the  instruments  to  be  employed,  before  an  explo- 
ration of  the  depth  and  possible  comphcations  of  a  scalp  wound  are 
begun.  The  injury  of  the  larger  arteries  of  the  scalp  can  be  suspected 
when  the  hemorrhage  is  profuse  and  of  a  spurting  character,  especially 
2  17 


15  SURGICAL    AFFECTIONS    OF   THE    HEAD. 

when  the  wounds  are  situated  close  to  the  frontal,  temporal,  or  occip- 
ital arteries. 

Contused  Wounds  of  the  Scalp. — ^The  diagnosis  of  these  must 
be  made  from  a  consideration  of  the  age,  the  history,  and  the  local 
findings.  They  may  be  quite  superficial,  causing  only  shght  swelling 
and  discoloration  of  the  skin,  or  deeper,  resulting  in  quite  visible  tumors 
(Fig.  i).     The  diagnosis  of  the  former  presents  no  difficulties. 

In  the  deeper  or  more  severe  form  anatomical  pecuharities  play 
a  role.  In  infants  and  young  children  contusions  of  the  scalp  are 
often  followed  by  marked  swelling.  This  is  especially  the  case  in 
infants  following  a  difficult  labor,  where  considerable  pressure  has 
been  exerted  upon  the  head  by  instruments  or  by  the  bony  pelvis. 


Fig.  I.— Location  of  Various  Hemorkhages  in  the  Scalp. 
SK  and  AP  represent  the  cutaneo-aponeurotic  layer;  P,  pericranium;   S,  skull;    i,  superficial  hematoma 
or  contusion  in  skin  proper  of  scalp;  2,  hemorrhage  or  pus-formation  in  subaponeurotic  layer;  3,  subpericranial 
hemorrhage.     The  latter  is  the  location  of  the  hemorrhage  in  the  cephalhematoma  of  infants. 


Such  swellings  are  called  ce phalhematomata ,  and  are  the  result  of  an 
extravasation  of  blood  between  the  pericranium  and  the  skull  (Fig.  i). 
The  pericranium,  as  was  stated  above,  is  loosely  attached  except  along 
the  sutures;  hence  the  diagnostic  features  are  that  these cephalhemato- 
mata  are  situated  over  one  or  both  parietal  bones  (Fig.  2),  and  can  be 
followed  until  they  terminate  at  the  sutures  (either  coronal,  sagittal,  or 
lambdoidal).  They  fluctuate,  but  do  not  pulsate  or  increase  in  size 
when  the  child  cries.  The  absence  of  the  latter  two  features  in  ceph- 
alhematomata  and  the  fact  that  meningoceles  almost  always  occur  in 
the  frontal  or  the  occipital  region  enable  one  to  differentiate  these 
two  conditions  in  the  scalps  of  young  infants.  At  a  later  period  (four 
to  six  weeks)  a  zone  of  ossification  often  begins  at  the  edge  of  a  ceph- 


INJURIES    OF   THE    SCALP. 


19 


alhematoma,  and,  in  the  absence  of  the  history,  a  fracture  might  be 
thought  of.  The  hmitation  of  the  swelhng  by  the  sutures,  the  distinct 
fluctuation  to  be  obtained,  and  the  fact  that  pressure  does  not  reveal 
any  defect  in  the  skull  or  cause  any  cerebral  symptoms,  enable  one 
to  exclude  a  fracture. 

A  cephalhematoma  may  at  times  occur  without  the  history  of 
injury  in  scorbutic  and  rachitic  children,  and  be  mistaken  for  an  abscess 
following  tuberculosis  of  the  cranial  bones. 

It  would  seem  advisable  in 
connection  with  the  subject  of 
cephalhematoma  in  infants 
and  young  children  to  call  at- 
tention to  a  swelling  which 
may  produce  a  considerable 
elevation  of  the  overlying  intact 
scalp.  This  swelhng  follows 
an  injury  to  the  scalp  and  skull 
in  children  in  the  first  three  or 
four  years  of  life,  and  is  called 
traumatic  cephalhydrocele  (Fig. 
3)  or  meningocele  spuria  trau- 
matica. The  injury  may  have 
been  accompanied  by  symp- 
toms of  cerebral  concussion  or 
contusion,  but  at  times  cases 
present  themselves  years  after 
such  an  injury,  or  the  latter 
has  been  so  insignificant  that 
no  importance  is  ascribed  to  it. 
Such  swellings  may  appear 
over  any  part  of  the  vertex  of 
the  skull,  and  are  due  to  the 

accumulation  of  cerebrospinal  fluid  between  the  scalp  and  the  skull,  which 
has  escaped  through  an  opening  following  a  fracture.  These  swellings 
have,  as  a  rule,  a  pulsation  which  is  synchronous  with  that  of  the  heart, 
but  cases  have  been  recorded  where  there  is  no  pulsation.  The  swelhng 
can  be  reduced,  and  when  this  is  done,  the  edges  of  the  skull  opening  can 
be  felt.  Often  such  a  reduction  causes  compression  symptoms.  These 
spurious  or  false  meningoceles  must  be  differentiated  from  the  follow- 
ing conditions : 

I.  Deep  cavernous  angiomata.     These  may  show  distinct  fluctuation 


^   .^^^^^m^ 

^ 

^1 

f 

^K^-      -^ 

1     j|LjHH|^||QgEgM| 

1 

1 
1 
1 

Fig.  2. — Cephalhematomata  of  Newborn  Child. 

I,  Hematoma  over  right  parietal  bone;  2,  hematoma  over 

left  parietal  bone. 


20 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


and  pulsation  and  can  be  decreased  in  size  by  compression,  but  firm 
pressure  upon  the  veins  leading  to  them  will  cause  all  these  signs  to  dis- 
appear. In  addition  there  is  no  peripheral  elevation  of  bone,  and  no 
defect  in  the  skull  can  be  felt. 

2.  Hematomata  or  blood- cysts  beneath  the  pericranium,  following 
fractures  of  the  skull,  which  communicate  with  the  longitudinal  or 
lateral  sinuses.  They  are  often  called  sinus  pericranii,  and  are  quite 
rare,  only  ten  cases  having  been  reported.  They  are  more  prominent 
when  the  patient  bends  forward,  and  are  due  to  the  rupture  of  an  emis- 
sary vein  which  does  not  heal  and  which  communicates  with  a  sinus. 

3.  Congenital  meningocele  and  encephalocele.  These  have  a 
somewhat  constant  location  in  the  frontal  or  the  occipital  region;  there 


'%MIII§^r^--'j0m, 


Fig.  3. — Meningocele  Spuria  Traumatica  CBayertlial). 


is  an  absence  of  a  history  of  injury,  and  the  defect  in  the  skull  is  round 
and  smaller  than  the  tumor  itself. 

4.  Soft  sarcomata  of  the  dura  which  form  subcutaneous  tumors 
after  penetrating  the  skull.  These  may  pulsate,  and  can  be  reduced 
by  pressure,  but  do  not  fluctuate,  and  there  is  usually  a  history  of 
gradual  growth  without  preceding  trauma. 

In  older  children  and  in  adults,  contusion  of  the  scalp  may  be  fol- 
lowed by  a  hematoma  in  the  subcutaneous  tissue,  forming  a  swelHng 
which  can  be  moved  upon  the  skull  (superficial  hematoma),  or  it  may 
result  in  the  escape  of  a  larger  or  smaller  quantity  of  blood  into  the 
subaponeurotic  layer  (Fig.  i).  As  was  stated  above  (see  page  17), 
the  pericranium  in  the  adult  is  so  firmly  attached  to  the  skull  that  the 


INJURIES    OF   THE    SCALP. 


21 


escape  of  blood  beneath  it  is  not  sufficient  to  be  recognized,  in  the  absence 
of  a  penetrating  wound.  A  subaponeurotic  or  deep  hematoma  often 
follows  a  severe  contusion  of  the  scalp.  Its  edges  are  frequently  firm 
and  elevated  and  its  center  depressed,  resembling  under  these  con- 
ditions a  depressed  fracture  of  the  skull.  By  passing  the  finger  firmly 
from  the  surrounding  uninjured  scalp  across  the  peripheral  elevation, 
one  will  find  that  the  latter  is  above  the  level  of  the  skull  (Fig. 
4)  and  can  be  pressed  away.  The  edges  of  such  a  hematoma  lack 
the  hardness  of  the  skull  bone  and  also  the  sharp  outline  of  a  fractured 
bone. 

In  some  cases,  especially  when  there  is  an  accompanying  coma 
of  uncertain  origin  and  non- 
surgical conditions  have  been 
ehminated,  the  diagnosis  of  a 
simple  contusion  of  the  scalp 
is  perplexing  and  justifies  an 
exploratory  incision  carried 
out  under  proper  precautions. 
The  diagnosis  becomes  espec- 
ially difficult  when  the  patient 
is  seen  several  days  after  the 
injury,  and  an  infection  of  the 
hematoma  has  begun  (see  page 
66). 

The  hematoma  may  be 
quite  extensive  and  communi- 
cate with  a  ruptured  artery 
of  the  scalp,  causing  distinct 
pulsations  (pulsating  hema- 
toma). 

At  times  after  a  fracture  of  the  vertex,  especially  in  children,  a  large 
hematoma  will  form  without  a  scalp  wound,  but  accompanied  by  symp- 
toms of  compression  (see  page  36).  In  one  case  observed  by  the 
author  there  was  a  direct  communication  between  the  scalp  hematoma 
and  a  ruptured  middle  meningeal  artery.  The  compression  symptoms 
are  the  only  means  of  diagnosing  such  an  injury,  and  in  their  absence 
it  would  be  impossible  to  trace  any  relation  between  a  large  hematoma 
of  the  scalp  and  intracranial  hemorrhage. 


n  lL 

— 1 

Bone 

A 

mj( 

^^^ 

1 

J 

Pt 

Soft  center 
of  hemato- 
ma 

\'l 

'  •     \ 

\ 

[ard  edge  of 
hematoma 

11 

fe\ 

-4- 

! 

Brain 

i 

J 

Fig.  4. — Hematoma  of  Scalp,  the  Soft  Center  and 
Firm  Edge  of  which  often  Simulate  Fracture 
(Scudder). 


22  SURGICAL    AFFECTIONS    OF   THE   HEAD. 

FRACTURES  OF  THE  SKULL. 

The  diagnosis  of  a  fracture  of  the  skull  must  be  based  upon  a  con- 
sideration of  the  following  points : 

I.  The  history  of  the  mode  of  injury. 
II.  The  direct  examination  of  the  vertex. 

III.  The  interpretation  of  certain  special  signs  indicating  fracture 
of  the  base. 

IV.  Evidences  of  injury  of  the  intracranial  structures. 

L  History  of  the  Mode  of  Injury. 

At  the  time  of  the  accident  this  is  of  subordinate  value,  because 
a  careful  estimate  of  the  evidence  obtained  from  the  other  three  factors 
will  usually  enable  a  diagnosis  to  be  made.  At  a  later  period,  however, 
the  possibihty  of  a  fracture  having  been  the  result  of  a  certain  mode 
of  injury  may  arise,  and  an  exact  history  should  be  obtained. 

In  general,  fractures  of  the  skull  are  produced  by  a  force  acting 
in  one  of  two  ways :  First,  upon  some  one  point  in  the  skull;  for  example, 
a  blow  with  a  hammer,  a  bayonet,  or  a  bullet.  A  fracture  is  far  more 
likely  to  occur  where  the  force  acts  thus  on  a  circumscribed  area  than 
in  the  second  variety,  where  it  is  distributed  in  meridians  radiating 
from  the  point  of  impact,  and  perhaps  producing  a  fracture  at  some 
distant  point,  where  the  elasticity  of  the  bone  yields.  A  fall  upon  the 
vertex,  the  feet,  or  the  buttocks  is  an  example  of  a  force  acting  thus 
in  a  more  diffuse  manner  and,  as  a  rule,  a  fracture  is  not  so  Hkely  to 
follow  it.  The  history  of  a  gunshot  or  a  punctured  wound  of  the 
mouth  or  orbit  is  of  aid  in  diagnosing  a  fracture  of  the  base. 

The  history  may  be  of  some  confirmatory  value  in  the  following 
instances:  (a)  Where  a  hematoma  of  the  scalp  (see  page  21)  resem- 
bles a  simple  depressed  fracture.  Here  the  history  of  some  force  apphed 
in  a  concentrated  manner  should  lead  one  to  examine  for  other  evidences 
of  fracture,  such  as  those  of  intracranial  injuries,  (b)  Where  bleeding 
from  the  nose  and  ears  and  other  signs  of  basal  fracture  exist  without 
coma,  etc.  A  fall  upon  the  vertex  may  by  transmission  of  force  produce 
a  fracture  at  the  base  by  meridional  distribution  and  such  a  history  will 
be  of  aid  in  confirming  the  above  evidences  of  a  fracture  of  the  base, 
(c)  When  Jacksonian  epilepsy  has  developed,  the  likelihood  of  a  frac- 
ture having  been  sustained  at  the  time  of  injury  is  greater  if  there  is  a 
history  of  a  blow  having  been  struck  by  some  instrument  or  missile 
(e.  g.,  mallet,  iron  bar,  a  rock,  etc.)  capable  of  producing  a  .circum- 
scribed injury. 


FRACTURES    OF   THE    SKULL. 


23 


II.  Examination  of  the  Vertex. 

This  must  be  made  under  one  of  two  conditions :  (a)  Where  no  open 
wound  exists  as  a  result  of  tlie  accident,  as  is  the  case  in  simple  fractures; 
(&)  where  a  wound  of  the  scalp  leads  either  directly  or  indirectly  to 
the  seat  of  the  fracture,  as  in  compound  fractures. 

(a)  Where  no  Scalp  Wound  is  Present. — Under  these  circumstances 
our  only  method  of  diagnosis  from  an  examination  of  the  skull  lies 
in  direct  palpation  of  a  lissure  or  of  a  depression.  In  the  case  of  a 
fissure  this  is  usually  impossible  unless  the  fissure  is  very  wide,  and 


Fig.  s. — Simple  Depressed  Fracture  of  the  Skull  in  an  Infant,  without  Symptoms.     No  Treat- 
ment.   Gradual  Disappearance  of  Depression  (Elliot's  Case). 


in  the  absence  of  more  direct  evidence  of  intracranial  injury  is  abso- 
lutely unreliable  as  an  aid  to  diagnosis.  In  the  case  of  a  depression 
apparently  in  the  vertex,  which  can  be  felt  by  passing  the  finger  over 
the  intact  scalp,  the  following  conditions  must  be  excluded  before  a 
diagnosis  of  depressed  fracture  s'hould  be  made. 

1.  The  possibihty  of  a  hematoma  of  the  scalp  resembling  a  depressed 
fracture  (see  page  21). 

2.  Normal  depressions  in  the  adult  skull,  especially  in  the  aged. 
One  should  always  compare  the  two  sides  of  the  skull  a  number  of 
times  when  palpating  it  through  the  intact  scalp. 

3.  Depressions  due  to  congenital  defects,  e.  g.,  meningocele. 


24 


SURGICAL    AFFECTIONS    OF    THE    HEAD. 


4.  Depressions  due  to  the  presence  of  Wormian  bones. 

5.  Depressions  following  the  softening  of  syphilitic  gummata  with 
thickening  of  the  periosteum  at  the  edges  of  such  a  depression. 

6.  Depressions  due  to  pressure  on  the  head  by  the  bony  pelvis  or 
by  forceps  during  birth.  Such  depressions  can  occur  in  the  infant's 
skull,  owing  to  its  great  elasticity,  and  upon  first  examination  feel  hke 
a  depressed  gutter  fracture.  They  rarely  persist,  but  correct  themselves 
spontaneously  within  a  few  weeks  (Fig.  5). 

In   a   case  of   depressed  fracture   occurring  without    scalp    injury 


Fig.  6. — Location  of  Most  Frequent  Lines  of  Fissured  Fraci'URE  of  the  Sk'ull,  Extending  into 

THE  Base. 

Fissure  extending  through  temporo-parietal  bone  into  middle  fossa;  2,  fissure  extending  through  occipital 

and  temporal  bones  into  base  of  skull,  the  petrous  portion  of  the  temporal  bone. 


the  palpation  of  the  irregular  sharp  edges  of  the  bone  will  serve  to 
distinguish  it  from  the  smooth  edges  of  a  congenital  defect.  The 
frequent  location  of  the  congenital  defects  in  the  parietal  and  occip- 
ital bones,  will  also  be  of  aid. 

In  a  case  of  depression  following  syphilis  the  history  and  the  pres- 
ence of  other  evidences  of  the  tertiary  stage  will  clear  up  the  diagnosis. 

At  the  present  time  the  surgeon  should  never  be  content  with  making 
a  diagnosis  of  depressed  fracture  of  the  vertex  without  a  visual  inspec- 
tion of  the  skull  through  an  exploratory  incision  made  under  proper 
precautions. 


FRACTURES    OP   THE    SKULL. 


25 


(b)  Examination  0}  the  Vertex  where  a  Wound  0}  the  Scalp  Exists 
(Compound  Fracture). — Under  these  conditions  the  diagnosis  is  com- 
paratively easy  in  the  majority  of  cases  by  both  inspection  and  palpa- 
tion at  the  seat  of  fracture  if  the  patient  is  seen  immediately  after  the 
injury. 

A  fissured  fracture  can  be  recognized  as  a  fine,  hair- like  opening, 
from  which  blood  escapes  (Figs.  6,  7,  and  8).  At  times  the  edges  may 
gape.  The  fissure  can  be  followed  in  many  cases  until  it  disappears  at 
the  base  of  the  skull.  One  can  differentiate  it  from  a  suture  by  the  fact 
that  it  is  impossible  to 
rub  the  blood  away  in 
the  case  of  a  fracture. 
The  diagnosis  is  con- 
firmed in  many  cases 
by  evidences  of  frac- 
ture of  the  base  (see 
below),  or  by  those  of 
intracranial  injury  (see 

page  34)- 

A  depressed  frac- 
ture of  the  vertex  can 
be  readily  diagnosed 
when  the  edges  of  the 
scalp  wound  are  re- 
tracted. The  depres- 
sion may  be  linear,  7'.^., 
there  may  be  one  or 
more  large  fragments 
which  have  slipped 
under  and  are  firmly 
fixed  beneath  the  ad- 
jacent skull,  or  the  depression  may  be  gutter-like  or  saucer-like,  the 
center  of  the  depression  resembling  the  center  of  a  star,  from  which 
the  lines  of  fracture  radiate  (Fig.  14). 

The  diagnosis  of  a  punctured-  fracture  of  the  skull,  such  as  follows 
a  bayonet  thrust,  a  bullet,  or  the  use  of  some  sharp  projectile  can  be 
made — (a)  from  the  history;  (b)  from  the  appearance  of  the  scalp  wound, 
and  (c)  from  the  examination  of  the  skull  itself. 

The  question  may  arise.  How  deep  does  the  fracture  extend  ?  It 
may,  in  general,  be  said  that : 

I.  Fractures  of  the  external  table  alone  can  be  diagnosed  positively 


Fig.  7. — Fracture  of  Frontal  and  Nasal  Bones. 


26 


SURGICAL    AFFECTIONS    OF   THE   HEAD. 


as  only  involving  this  table,  if  the  fragments  are  removed.  Such  a 
fracture  may  occur  when  the  skull  is  struck  obliquely  by  a  sharp  instru- 
ment, or  in  the  mastoid  or  the  frontal  regions,  where  a  considerable 
interval  exists  between  the  two  tables. 

2.  Fractures  of  the  internal  table  alone  can  be  diagnosed  only 
from  the  symptoms  of  the  accompanying  intracranial  injury. 

3.  Fractures  of  both  tables,  of  course,  exist  when  there  is  a  visible 
depression  and  after  the  majority  of  punctured  or  bullet  wounds. 
Under  the  latter  two  of  these  conditions  the  internal  table  is  more 
extensivelv  involved.     In  a  fissured  fracture  one  can  diamose  a  fracture 


Fig.  8. — Fracture  of  Occipital  Bone  Extending  into  the  Posterior  Fossa. 


of  both  tables  if  there  is  evidence  of  intracranial  injury  or  if  the  fissure 
is  enlarged  by  chiseling.  This  latter  step  is  never  justifiable  for  merely 
diagnostic  reasons  in  the  absence  of  serious  symptoms. 

Diagnosis  of  Fracture  of  the  Skull  at  a  Later  Period. — ^The 
question  may  arise  months  or  perhaps  years  after  an  injur}^,  when  one 
of  the  late  sequelce,  such  as  Jacksonian  epilepsy,  insanity,  etc.,  have 
developed,  as  to  whether  a  fracture  had  ever  occurred.  In  the  absence 
of  a  history  from  a  reliable  source,  we  must  depend  upon  our  objective 
examination,  which  may  show  one  or  all  of  the  following: 

I.  Deformity  in  the  shape  of  a  depression  of  the  vertex.  All  the 
conditions  enumerated  on  page  23  must  be  excluded. 


FRACTURES    OF   THE    SKULL.  27 

2.  Hyperesthesia  of  the  scalp,  which  can  be  determined  by  repeated 
tests. 

3.  A  painful  scar.  At  times  pressure  upon  such  a  cicatrix  may 
cause  an  aura. 

4.  Persisting  evidences  of  intracranial  injury  or  of  fracture  of  the 
base,  such  as  nerve  paralysis,  etc. 

5.  The  development  of  a  traumatic  cephalhydrocele  in  children 
is  positive  proof  of  a  fracture  having  occurred  (see  page  19). 

IIL  The  Interpretation  of  Certain  Special  Signs  of  Fracture  of 

THE  Base. 

The  diagnosis  of  a  fracture  of  the  base  of  the  skull  is  made  from 

one  or  more  of  the  following  signs : 

1.  Hemorrhages  into  or  the  presence  of  air  in  the  tissues  around 
the  base. 

2.  Escape  of  blood,  cerebrospinal  fluid,  or  even  brain  substance 
externally  from  certain  cavities,  such  as  the  ear,  nose,  and  mouth,  which 
communicate  with  the  seat  of  fracture. 

3.  Evidence  of  injury  of  the  cranial  nerves  or  of  the  vessels  at 
the  base  of  the  skuh. 

1.  Hemorrhages  or  the  Presence  of  Air  in  the  Tissues. — Ecchy- 
moses  appearing  in  the  eyelids,  around  the  mastoid,  or  the  nape  of  the 
neck  are  of  value,  if  the  blow  has  not  been  received  over  the  region  in 
which  the  subcutaneous  hemorrhages  have  occurred,  and  especially 
if  the  latter  begin  to  appear  some  hours  after  the  injury,  and  increase 
in  amount  in  the  first  few  days.  Orbital  (subconjunctival)  hemorrhages 
are  quite  frequently  present,  and,  if  excessive,  an  exophthalmos  may 
be  produced,  which  is  almost  positive  evidence  of  a  basal  fracture. 
Escape  of  air  into  the  subcutaneous  tissues,  producing  emphysema  or 
a  crackling  sensation  of  the  skin  upon  palpation,  only  occurs  after  frac- 
tures comriiunicating  with  the  mastoid  cells  or  frontal  sinuses,  and,  when 
found,  is  positive  evidence  of  a  fracture. 

2.  Escape  of  Blood,  etc.,  from  the  Ear,  Nose,  and  Mouth. — ^The 
escape  of  blood  from  the  ear  from  other  causes  than  a  fracture  of  the 
base  is  of  short  duration  and  small  in  amount.  Bleeding  may  occur 
from  one  ear  alone,  and  this  is  very  frequent,  or  it  may  take  place  from 
both.  If  it  spurts,  the  internal  carotid  artery  must  have  been  torn. 
If  it  occurs  in  very  large  quantity  without  pulsation,  a  large  sinus  has 
been  lacerated.  Bleeding  from  the  ear  can  be  said  to  be  clue  to  a  basal 
fracture,  if  after  cleansing  the  ear  and  wiping  out  the  blood  one  ex- 
cludes the  following  sources  of  hemorrhage:    Tearing  of  the  cartilagi- 


25  SURGICAL   AFFECTIOXS    OF    THE    HEAD. 

nous  auditory  canal  in  its  anterior  or  posterior  ^Yall,  simple  rupture 
of  the  membrana  tympani,  and  flow  of  blood  from  wounds  of  the  scalp 
or  external  ear  into  the  canal.  The  first  and  last  of  these  can  be  elim- 
inated by  cleansing  the  ear  and  then  observing  the  reaccumulation  of 
blood.  The  rupture  of  the  membrana  t}mipani  causes  only  a  slight 
and  transitory  hemorrhage. 

Blood  escaping  from  the  nose  or  mouth  is  only  of  diagnostic  value 
if  one  can  exclude  local  injury,  and  if  it  persists  for  a  number  of  hours. 
Very  rarely  one  can  obsen-e  hemorrhage  in  the  retropharj^gneal  struc- 
tures or  the  escape  of  blood  from  the  Eustachian  tube,  when  the  mem- 
brana tympani  is  not  torn. 

The  flow  of  cerebrospinal  fluid  most  often  occurs  from  the  ear, 
and  can  be  distinguished  from  blood-serum  by  the  large  quantity  of 
fluid,  the  high  percentage  of  sodium  chlorid  and  the  small  percentage 
of  albumin  which  it  contains. 

Less  frequently  cerebrospinal  fluid  may  escape  from  the  mouth  or 
nose.  Several  cases  have  been  reported  where  a  diagnosis  of  basal 
fracture  has  been  confirmed  by  the  flow  of  cerebrospinal  fluid  persisting 
for  years  after  the  injur}''  (rhinorrhea).  The  flow,  whether  from  the 
nose,  mouth,  or  ear,  is  increased  by  coughing  or  any  form  of  exertion. 

The  escape  of  brain  tissue  is  rare,  except  in  fractures  involving  the 
orbit  or  the  temporal  bone,  and,  when  present,  is  absolute  evidence  of 
a  fracture.     One  can  then  find  ganglion- cells  microscopically. 

3.  Injuries  of  the  Nerves  and  Vessels  at  the  Base. — lai  Inju- 
ries of  Nerves  in  Basal  Fractures. — In  the  majority  of  fractures  of  the 
base,  certain  cranial  nen-es  are  more  frequently  injured  than  others, 
owing  to  the  fact  that  the  majority  of  the  fractures  pass  through  the 
petrous  portion  of  the  temporal  bone  (Fig.  12),  and  from  here  forward; 
hence  one  should  always  examine  a  patient  for  evidences  of  paralysis 
of  the  seventh,  sixth,  third,  and  fourth  ner\-es  in  the  order  named,  and 
then  the  remaining  nerves.  At  the  same  time  one  must  not  forget  that 
injuries  of  all  of  these  nen^es  can  occur  without  fracture  of  the  base, 
so  that  a  diagnosis  of  fracture  should  not  be  made  from  nerve  paralysis 
alone,  but  by  careful  consideration  of  the  other  signs,  as  subcutaneous 
hemorrhages,  flow  of  blood  or  cerebrospinal  fluid  from  ears,  nose,  and 
mouth,  with  the  evidences  of  nerve  or  ^'essel  injury  at  the  base.  In 
addition  to  these  three  factors,  in  making  a  diagnosis  a  fourth  is  to  be 
added,  and  that  is  whether  the  accompanying  signs  of  injury  to  the 
brain  fto  be  considered  later)  confirm  the  diagnosis  already  rendered 
probable  by  the  other  three. 

Injury  of  the  Facial  Nerve. — This   shows   itself   as   a   peripheral 


FRACTURES    OF   THE    SKULL. 


29 


paralysis  affecting  the  ocular,  labial,  and  nasal  groups  of  muscles. 
When  the  case  is  first  examined,  this  paralysis  is  best  demonstrated  by 
pressure  upon  the  supraorbital  nen^es,  as  shown  in  Fig.  9.  This 
manipulation,  unless  the  coma  is  extremely  deep,  causes  such  pain 
that  the  patient  will  contract  the  facial  muscles  of  the  non-paralyzed 


Fig.  g. — Method  of  AL^king  pKLbSUKE  upon  the  Supraorbital  Ner\-es. 
To  be  employed  in  the  diagnosis  of  certain  intracranial  affections  (see  text).     The  examiner  should  stand  be- 
hind the  patient's  head,  and  make  pressure  with  the  index-finger  of  each  hand  over  the  supraorbital  notches. 


side.     It  is  also  of  aid  in  distinguishing  genuine  from  feigned  uncon- 
sciousness or  from  an  alcohohc  stupor. 

The  paralysis  of  the  facial  nerve  is  usually  unilateral,  and  may  in- 
volve other  branches  of  the  nerve  beside  those  supplying  the  muscles 
of  expression.  The  paralysis  is  rarely  permanent.  It,  like  evidences 
of  injury  to  all  the  nerves  at  the  base,  may  not  appear  at  the  time  of 
the  accident,  but  several  days  later,  owing  to  a  secondar}^  periostitis. 


3° 


SURGICAL    AFFECTIONS    OF   THE    HEAD. 


Injuries  of  the  Third,  Fourth,  and  Sixth  Nerves. — Injuries  of  the 
third  cranial  or  motor  oculi  nerve  cause  external  strabismus  and  ptosis. 
The  pupil  is  widely  dilated  and  does  not  react  to  either  hght  or  accom- 
modation. There  is  also  double  vision.  Injury  of  the  fourth  nerve 
causes  diplopia.  In  attempts  at  downward  convergent  vision  the  in- 
ternal rotation  of  the  eyeball  fails  to  take  place. 

Paralysis  of  the  sixth  nerve  results  in  internal  strabismus  and  marked 
diplopia.     The  injuries  of  all  these  nerves  are  usually  unilateral,  owing 

to  their  involvement  in  frac- 
tures involving  the  base  close 
to  the  apex  of  the  orbit. 

Injury    of     the     Auditory 

Nerve. — ^According    to     some 

authors  (Rawling),  the  seventh 

and   eighth   nen^es   are  more 

frequently   injured    than   any 

others,  but  others  (Graf  and 

Brun),     from     the     analysis 

of  a   large   number  of  cases, 

state    that     the    order    given 

above,    viz.,    seventh,     third, 

fourth,   and  sixth,    represents 

the   greater  frequency  of  in- 

.  ^k  .  volvement. 

„^p\  """*  .^^  The  eighth  nen-e  is  most 

wK  iH^^^^^        frequently  involved  in  fracture 

■^  ''"^^^^^^^k        of  the  base  with  the  seventh, 

and  upon  this  association  rests 
much  of  the  question  as  to 
whether  the  deafness  resulted 
from  the  injury.  If  the  audi- 
tory nerve  is  injured  there  is 
loss  of  hearing  by  bone  con- 
duction and  loss  of  hearing  of  the  higher  tones. 

Injuries  of  the  Olfactory  Nerve. — ^The  effect  of  injury  to  this  nerve 
is  anosmia,  or  a  loss  of  sense  of  smell  on  the  side  of  injury.  The  presence 
of  anosmia  aids  in  locahzing  the  fracture  in  the  anterior  fossa  (cribri- 
form plate  of  ethmoid).  One  must  rule  out  hysteria,  catarrhal  nasal 
conditions,  and  fifth-nerve  disturbances. 

Injury  of  the  Optic  Nerve. — ^A  fracture  of  the  base  may  be  followed 
by  choked  disc,  because  the  dural  covering  of  the  nerve  is  injured; 
this  quickly  subsides,  but  an  optic  atrophy  may  remain. 


Fig.  10. — Facial  Paralysis  of  Peripheral  Origin 
Following  Gunshot  Wound  of  Right  Facial 
Nerve . 

Note  the  inability  to  contract  the  muscles  of  the 
eyelids  and  the  muscles  of  expression  of  the  face  proper, 
resulting  in  obliteration  of  the  nasolabial  fold  and  droop- 
ing of  the  angle  of  the  mouth. 


FEACTURES    OF    THE    SKULL. 


31 


Injury  0}  the  Trigeminal  Nerve. — This  nerve  is  seldom  involved 
in  fractures  of  the  base.  There  are  both  sensory  and  motor  disturbances . 
The  motor  are  loss  of  function  of  the  masseter  and  pter}^goid  muscles 
on  the  side  of  the  injury,  so  that  the  patient  is  unable  to  keep  the  jaws 
tightly  together.  The  loss  of  sensation  involves  almost  the  entire 
lateral  half  of  the  face,  the  conjunctiva,  nasal  and  buccal  mucous  mem- 
branes, including  the  tongue,  often  causing  a  trophic  ulcer  of  the  cornea. 

Injury  of  the  Ninth,  Tenth,  and  Eleventh  Nerves. — Comparatively 
few  cases  of  injuries 
to  these  nerves  have 
been  reported  follow- 
ing fracture  of  the 
base.  The  paralyses 
of  all  three  of  these 
nerv'es  are  often  asso- 
ciated, on  account  of 
their  close  relation  at 
the  base.  In  four  of 
the  cases  reported 
there  was  dysphagia 
from  paralysis  of  the 
palatal  muscles. 
There  were  also  dis- 
turbances of  speech 
and  of  voice,  due  to 
paralysis  of  the  recur- 
rent larvTigeal.  In 
three  of  live  cases  there 
was  unilateral  anes- 
thesia of  the  pharynx 
and  lariTLx,  and  in  two, 
disturbances  of  taste. 

In  several  cases  in 
which  there  has  been  predominant  involvement  of  the  eleventh  or  spinal  ■ 
accessory,  it  produces  difficulty  in  raising  of  the  arm,  due  to  paralysis  of 
the  trapezius  (Fig.  11). 

Injuries  of  the  Twelfth  or  Hypoglossal  Nerve. — This  ncr\-e  is  also 
rarely  involved,  very  few  cases  ha\'ing  been  reported.  Its  paralysis 
causes  difficult  deglutition,  atrophy  of  the  tongue,  and  speech  is  affected. 
Its  injur}'  is  almost  always  in  association  with  that  of  the  ninth,  tenth, 
and  eleventh  nerves. 


Fig.  II. — Paralysis  OF  THE  Right  Tr.apezius  Muscle,  as  a  Re- 
sult OF  Cutting  the  Spinal  Accessory  >s^erve  During  an 
Operation  for  Tubercular  Glands  of  the  Neck. 

P,  Points  to  the  paralyzed  muscle.  Observe  the  depression  on  the  right 
side  of  the  neck  (paralyzed  side). 


32 


SURGICAL   AFEECTIOXS    OF    TPIE   HEAD. 


(b)  Injuries  of  the  Vessels  at  the  Base  of  the  Skull  in  Fractures  of  the 
Same. — ^The  diagnosis  of  these  is  considered  on  page  28.  Special 
interest,  however,  is  attached  to  cases  of  fractures  of  the  base  accom- 
panied by  wounds  of  the  internal  carotid  arter}'  and  cavernous  sinus 
simultaneously,  resulting  in  the  formation  of  an  arteriovenous  aneu- 
rysm. This  result  of  a  fracture  of  the  base  can  be  diagnosed  by  the 
presence  of  a  pulsating  exophthalmos.  There  is  marked  protrusion 
of  the  eyeball;  the  upper  eyelid  is  swollen  and  tense,  and  there  is  a  dis- 


FiG.  12. — Most  Frequkxt  Lines  of  Fracture  of  Base  of  Skull. 
The  black  arrows  indicate  their  direction  if  they  traverse  further  than  indicated  in  the  illustration:  i,  Frac- 
ture of  anterior  fossa;  2,  3,  fractures  of  middle  fossa;  4.  fracture  of  posterior  fossa. 


tinct  pulsation  and  thrill— the  latter  two,  in  cases  where  the  common 
carotid  is  compressed.  Pulsating  exophthalmos  may,  however,  fohow 
a  fracture  (gunshot  wound  of  petrous  portion  of  temporal)  at  another 
part  of  the  skull,  as  reported  by  Barnard,^  and  then  be  due  to  a  sac- 
culated aneur}-sm  of  the  internal  carotid,  without  venous  communi- 
cation. 

Diagnosis  of  Fracture   of  Individual   Fossae   of   the  Base. — 
In  addition   to   being  able  to   make   a   chagnosis   of  fracture   of  the 

^  "Annals  of  Surgery,"  May,  1904. 


FEACTURES    OF   THE    SKULL. 


33 


base,  it  may  become  necessary  to  ascertain  through  which  fossae  the 
fracture  has  occurred.  The  majority  of  fractures  of  the  vertex  due  to 
a  fall  from  a  height  or  a  blow  upon  the  skull  by  some  blunt  instrument 
are  followed  by  a  fracture  of  the  corresponding  fossa  of  the  base.     In 


-S    «    •£ 


Anterior  branch  of 

middle  meningeal 

artery 


Gasserian  ganglion 


Posterior  branch  of 

middle  meningeal 

arteri,' 

Superior  petrosal 

sinus 


Olfactory  nerve 


Optic  nerve 
-(  Internal  carotid  artery 


Facial  nerve 

—  Auditory  nerve 
■4 — -  \"agus  nerve 
"*      Glossopharv'ngeal  n. 
Spinal  accessory  n. 


Sigmoid  sinus 


Hypoglossal  nerve 
Lateral  sinus 


Fig.  13. — View  of  Base  of   Skull,  SnovfiNG   Relation   of  Cranial  Nerves,  Carotid  and  Middle 

Meningeal  Arteries,  and  Sinuses  to  the  Foss^e. 
This  illustration  shows  on  the  right  side  of  the  skull  the  most  frequent  lines  of  fracture  at  the  base  of  the  skull. 


many  cases  of  fracture  of  the  base  following  a  punctured  or  gunshot 
wound  the  location  of  the  wound  of  entrance  is  of  assistance. 

The  greater  number  of  basal  fracture  Hncs  pass  through  the  petrous 
portion  of  one  or  both  temporal  bones,  either  as  extensions  or  isolated 
fractures.^     Many  fractures  involve  two  or  more  fossas  (Fig.  12). 

^  Patel:  "  Revue  de  Chirurgie,"  April,  1903. 
3 


34  SURGICAL   AFFECTIONS    OF   THE    HEAD. 

Aside  from  these  facts,  the  following  table  may  be  of  aid  (Fig.  13): 

['  I.  Subconjunctival  and  subcutaneous  (eyelids)  hemor- 
rhages. 
.  Exophthalmos  (due  to  retrobulbar  hemorrhage). 

Fractures  of  anterior  fossae ■{   3.  Bleeding  or  escape  of  cerebrospinal  fluid  or  brain 

substance  from  the  nose  or  mouth. 
4.  Pulsating  exophthalmos. 
I  5.  Anosmia  (due  to  olfactory  nerve  injury). 
f   I.  Subcutaneous  hemorrhages  around  the  mastoid. 
!    2.  Bleeding  and  escape  of  cerebrospinal  fluid  or  brain 
I  substance  from  the    ear   and   mouth  (per  Eusta- 

Fractures  of  middle  f ossffi ■{  chian  tube) . 

3.   Signs  of  injury  of  second,  third,  fourth,  fifth,  sixth, 
and  at  times  of  seventh  cranial  nerves  (see  pages 
I  28,  29). 

f  I.  Subcutaneous  hemorrhages  at  upper  part  of  back 
of  neck. 

Fractures  of  posterior  fossae -j    2.  Evidence  of  injury  of  seventh,  eighth,  ninth,  tenth, 

eleventh,  and  twelfth  nerves. 
[  3.  Bleeding  from  the  ear. 

Albuminuria  and  glycosuria  have  been  reported  after  basal  fracture, 
but  are  of  no  diagnostic  value. 

IV.  Evidences  of  Intracranial  Injury. 

In  by  far  the  greater  number  of  cases  a  fracture  of  either  the  vertex 
or  the  base  is  accompanied  by  unconsciousness  and  other  symptoms 
of  intracranial  injury.  This  is  especially  true  of  depressed  fractures 
of  the  vertex,  fissured  fractures  of  the  temporal  region  (middle  menin- 
geal hemorrhage),  and  the  majority  of  fractures  of  the  base. 

The  diagnosis  of  which  particular  form  of  injury  to  the  intracranial 
structures  has  occurred  depends,  first,  upon  the  length  of  time  which 
has  elapsed  since  the  accident;  and,  second,  upon  a  careful  analysis  of 
the  symptoms. 

The  length  of  time  since  the  accident  is  of  value  because  there  is  a 
certain  sequence  in  which  symptoms  of  the  various  conditions  show 
themselves. 

1.  In  the  first  forty-eight  hours  concussion,  compression,  and  con- 
tusion^ symptoms  appear. 

2.  After  the  first  forty-eight  hours  symptoms  of  meningitis,  cere- 
bral abscess,  hernia  cerebri,  and  pyemia  from  sinus  thrombosis  begin 
to  appear.  Quite  rarely  compression  symptoms  may  show  them- 
selves for  the  first  time  some  days  after  an  injury,  a  condition  known 
as  late  traumatic  apoplexy  (page  53). 

'  The  term  contusion  is  synonymous  with  laceration  of  the  brain  or  non-penetrat- 
ing wound. 


CONCUSSION   OF   THE    BRAIN. 


35 


3.  x\fter  the  immediate  effects  of  injury  have  disappeared  or  im- 
proved, the  so-called  late  sequelas,  such  as  traumatic  neuroses,  epilepsy, 
and  chronic  traumatic  abscess,  may  appear. 

In  the  majority  of  cases  it  is  of  the  utmost  importance,  both  as 
regards  prognosis  and  treatment,  to  make  a  diagnosis  as  soon  as  possible 
after  the  accident.  This  can  be  done  at  times  after  the  first  examination 
of  the  injured  person.  In  other  cases  a  second  or  third  analysis  of 
the  symptoms  at  intervals  of  a  few  hours  will  usually  enable  a  diagnosis 
to  be  made,  even  where  two  or  more  of  tliese  intracranial  conditions 
should  chance  to  be  present  together. 

Concussion,  compression,  and  contusion  of  the  brain  usually  occur 
as  comphcations  of  fractures  either  of  the  vertex  or  base,  so  that  the 
symptoms  of  the  latter  lesions  must  be  taken  into  consideration 
in  the  diagnosis  of  intracranial  injuries.  It  must,  however,  not  be 
forgotten  that  serious  damage  to  the  brain,  intracranial  blood-vessels, 
and  nerves  may  also  occur  after  mere  contusions  of  the  skull,  after 
falls  upon  the  feet  or  buttocks,  or  after  blows  or  falls  upon  the  chin  or 
head  without  a  fracture  of  the  skull. 


CONCUSSION  OF  THE  BRAIN. 

Concussion  symptoms  always  appear  immediately  after  the  injury, 
but  vary  somewhat  in  their  severity.  They  occur  with  especial  fre- 
quency after  fractures  of  the  base.  Graf  found  concussion  symptoms 
in  76  of  90  cases  of  fracture  of  the  base.  There  are  three  classes  of 
cases:  (a)  mild;  (h)  moderately  severe,  and  (c)  severe.  In  those  who 
recover  from  the  immediate  effects  of  the  concussion  of  the  brain  there 
is  an  initial  stage  of  depression,  and  a  second  stage  of  irritation  or 
reaction. 


Mild  Cases. 

1.  Unconscious  for  a   few 

seconds    to     minutes, 
rarely  half  an  hour. 

2.  Pulse  but  little  affected. 

3.  Respirations      a      little 

slower  than  normal. 

4.  Skin  pale  and  cold. 

5.  Vertigo,     linnitus,      or 

flashes  of  light. 

6.  No   memory   of   events 

just    before    accident. 


STAGE  OF  DEPRESSION. 

Moderately  Severe. 

1.  Unconscious  for  a  num- 

ber of  hours. 

2.  Pulse    slo.w    and    small 

(between   40   and   60). 

3.  Respirations     slow    and 

shallow. 

4.  Skin     pale,      cold,    and 

clammy. 

5.  Pupils  contracted  or  di- 

lated   equal,    and    re- 
spond to  light. 

6.  No  memory  of  events  be- 

fore accident,  when  re- 
action sets  in. 


Severe. 

1.  Unconscious  for   a  short 

period,      followed       by 
death. 

2.  Pulse  rapid  and  weak. 

3.  Respirations  shallow  and 

rapid. 

4.  Skin  pale,  cold,  and  clam- 

my. 

5.  Pupils  same  as  in  moder- 

ately severe. 


36  SURGIC.AX   AFFECTIONS    OF   THE   HEAD. 

Stage  of  Deprjession. — {Continued.) 
iSIiLD  Cases.  Moderately  Severe.  Severe. 

7.  No  rise  in  blood-pres-       7.  Involuntarj^    micturition       7.  Same    as    in    moderately 
sure.  and  defecation.  severe. 

8.  Vomiting — either  during       8.  Subnormal  temperature. 

period  of  unconscious- 
ness or  upon  recover}^ 
from  same. 

9.  Traces  of  sugar  or  albu-       9.  Rise  in  blood-pressure  in 

min  or  both  in  urine.  early  portion,  but  rapid 

fall   as   vasomotor   and 
other     centers     in     the 
medulla   become    para- 
lyzed. 
10.  Rise   in    blood-pressures 
immediately    after 
trauma. 

SECOND  OR  STAGE  OF  IRRIT.\TION  OR  REACTION. 

1.  Pulse  becomes  stronger  and  more  rapid,  until  normal. 

2.  Respirations  deeper  and  more  rapid,  until  normal. 

3.  Surface  of  skin  becomes  warmer  and  redder. 

4.  Temperature  normal  or  slightly  above. 

5.  Great  mental  irritability  and  apathy. 

6.  Same  vomiting. 

The  symptoms  of  concussion  in  the  average  case  ynW.  be  considered 
below  in  differentiating  it  from  compression  and  contusion  (see  page 
54). 

COMPRESSION  OF  THE  BRAIN. 

The  symptoms  of  cerebral  compression  of  traumatic  origin  vary 
both  in  their  intensity  and  in  the  time  of  onset,  according  to  the 
cause. 

I.  Compression  from  sphntcrs  of  depressed  fracture  (Fig.  14). 
The  S}Tnptoms  appear  almost  immediately  after  the  injury  and  are  asso- 
ciated with  those  of  concussion  and  contusion  (see  table  on  page  54). 

II.  Compression  from  intracranial  hemorrhage. 

This  may  arise — {a)  from  the  middle  meningeal  arter}^  (extradural 
hematoma  or  extrameningeal  hemorrhage)  (Fig.  21). 

(b)  From  the  pia  araclmoid  (subdural  hematoma  or  intermeningeal 
hemorrhage). 

(c)  From  the  vertebral  arteries  and  intracranial  portions  of  the 
internal  carotids. 

{d)  From  the  venous  sinuses. 

Compression  from  any  of  these  causes  appears  in  one  of  four  ways: 
I.  First,  symptoms  of  concussion,  then  a  free  intcr\-al  followed  by 
compression  symptoms. 


COMPRESSION   OF   THE    BRAIN. 


37 


2.  Distinct  interval  after  accident  without  aay  symptoms  of  intra- 
cranial injur}^,  then  signs  of  compression  begin  to  appear. 

3.  No  perceptible  interval  between  the  symptoms  of  concussion  and 
of  compression,  the  symptoms  of  the  concussion  at 

first  obscuring  those  of  the  compression. 

4.  Compression  symptoms  rarely  appear  a  num- 
ber of  days  after  the  accident  (late  traumatic  apo- 
plexy) . 

III.  Compression  symptoms  from  infection  of  the 
meninges  or  the  brain,  or  from  tumors  of  the  brain. 
Signs  of  cerebral  compression  due  to  infection 
appear  after  the  first  forty-eight  hours. 

Compression  symptoms  due  to  extradural  hema- 
toma from  a  laceration  of  the  middle  meningeal  artery 
appear  early,  and  are  quite  marked  within  a  few  hours 
after  their  onset.     Hemorrhage  from  injury  of  the 
vessels  of  the  pia  arachnoid  or 
the    sinuses     cannot   be    distin- 
guished from  middle  meningeal 
hemorrhage  in  the    majority  of 
cases,  but  appears  later,  is  less 
rapid,  and  the  symptoms  are  not 
so  marked  (see  pages  48,  49). 

The  experimental  work  of 
Kocher^  and  of  Cushing^  on  the  subject  of  cerebral 
compression  is  being  so  rapidly  confirmed  by  chnical 
observations,  that  the  classification  given  by  them 
will  be  followed  here.  According  to  these  writers, 
there  are  four  stages  of  compression  of  the  brain. 

First,  or  State  of  Compensation. — ^There  are 
practically  no  symptoms  with  the  exception  of  severe 
headache,  which  maybe  due  to  irritation  of  the  dura. 
Second,  or  Stage  of  Incipient  or  Mild  Com- 
pression.— ^The  symptoms  of  this  stage  are  due  to  an 
obstruction  to  the  outflow  of  venous  blood  (dysdi- 
aemy rrhosis) .     They  are : 

(a)  Headache — location  varies  according  to  seal 
of  lesion. 
(b)  DeHrium,  great  irritability,  and  restlessness. 

^  Nothnagel's  "  Specielle  Pathologic,"  Bd.  ix,  3. 

^  "American  Journal  Medical  Sciences,"  June,  1903. 


Fig.  14. — Fracture  of 
Skull  with  De- 
pressed Fragments 
(Scudder). 

Compression  of  brain  by 
bone. 


Fig.  15. — Fracture  of 
Skull  with  Mid- 
dle Meningeal 
Hemorrhage  (Scud- 
der). 

Compression  of  brain  by 
blood. 


3°  SURGICAL    AFFECTIONS    OF    THE    HEAD. 

(c)  Dullness  of  perception. 

(d)  Pupils  contracted  or  unequal.  Mslv  have  conjugate  deviation 
of  eyeball. 

(e)  Choked  disc. 

(f)  Pulse  slower  than  normal  (50  to  70).  Tension  moderately 
increased. 

(g)  Respiration  slower  but  regular. 

(h)  Temperature  higher  than  normal  (101°  to  103°).  The  greater 
the  degree  of  compression,  the  higher  the  temperature. 

(j)  Rise  of  blood-pressure.  This  can  be  determined  by  the  use  of 
the  Riva-Rocci  apparatus  fFig.  16). 


Fig.    16. RiVA-RoCCI    SPHYGMOMAXOiCETER   AS    MODIFIED   BY    CoOK. 


In  cases  of  compression  of  the  second  stage  (incipient  or  mild 
compression),  there  will  be  moderate  increase  of  blood-pressure  to 
180  to  190  mm.  of  Hg.  If  this  does  not  rise,  it  indicates  that  the  intra- 
cerebral tension  has  not  increased.  Concussion  will  cause  a  rise  in 
blood-pressure  immediately  after  the  accident,  but  it  decreases  as  the 
symptoms  subside.  In  cases  where  moderate  compression  exists,  in 
addition  to  the  concussion,'  the  blood-pressure  either  remains  stationar\' 
or  there  is  a  hght  rise,  due  to  a  posttraumatic  cerebral  edema  fCannon- 
BullardM. 

Third,  or  Stage  of  Advanced  Compression. — In  this  stage  the 
compression  is  so  great  as  to  cause  an  anemia  of  the  brain  both  of 

^  "Boston  Medical  and  Surgical  Journal,"  August,  1901. 


COMPRESSION    OF    THE    BRAIN.  39 

the  cortex  and  medulla  (adiajmyrrhosis).  The  vasomotor  center  is 
stimulated  and  causes  such  a  rise  in  blood-pressure  that  it  compensates 
for  the  increased  intracranial  tension.  The  diagnosis  of  this  stage  of 
compression  may  be  made  from  the  following  (see footnote^)  symptoms: 

(a)  The  patient  is  deeply  stuporous  and  gradually  becomes  coma- 
tose. 

(b)  The  pupil  is  dilated  and  not  responsive  on  the  side  of  the  lesion. 
There  may  be  conjugate  deviation  of  the  eyeballs  toward  the  side  of  the 
lesion. 

(c)  Marked  choked  disc. 

(d)  Pulse  very  slow.     May  drop  to  40  or  50  and  is  of  high  tension. 

(e)  Respirations  much  slower  and  stertorous.  They  may  be 
Cheque-Stokes  in  character. 

(/)  Temperature  higher  than  normal.  It  rises  as  compression 
increases. 

(g)  Blood-pressure  greatly  increased.  In  case  the  hemorrhage 
(if  this  be  the  cause  of  the  compression)  is  subdural  (intermeningeal), 
the  increase  is  slow^  and  only  moderate;  if,  however,  there  is  a  large 
extradural  clot  or  a  large  fragment  of  depressed  bone,  the  rise  will  be 
rapid  and  quite  marked,  falhng  soon  after  the  pressure  is  reheved, 
or  if  this  does  not  occur,  the  fourth  or  stage  of  paralysis  sets  in,  with 
its  marked  fall  of  blood-pressure.  Following  the  primary  fall  after 
the  operation  there  may  be  a  second  rise,  due  to  a  variable  degree  of 
cerebral  edema. 

(h)  Focal  symptoms.  These  may  or  may  not  be  present,  according 
to  whether  the  pressure  is  or  is  not  exerted  over  a  localized  area.  If 
present,  there  may  be  hemiplegia  of  the  face,  arm,  and  leg  of  the  opposite 
side,  or  a  monoplegia  of  the  arm  or  leg,  at  times  accompanied  by  twitch- 
ings  or  convulsions  of  the  affected  muscles.  There  is  also  increase  of 
the  deep  or  tendon  reflexes,  with  loss  of  control  of  the  bladder  and 
rectum. 

Fourth,  or  Stage  of  Paralysis. — In  this  stage  the  intracranial 
tension  can  no  longer  be  compensated  for  by  increased  blood-pressure, 
and  there  is  inhibition  of  the  functions  of  the  medulla  through  extreme 
anemia.  The  symptoms  are  us'ually  preceded  by  those  of  the  third, 
or  stage  of  advanced  compression.  In  this  fourth  or  paralytic  stage 
the  diagnosis  may  be  made  from  the  following: 

(a)  Deep  coma.     The  patient  cannot  be  aroused. 

(b)  The  pupils  are  dilated  and  not  responsive. 

^  The  symptoms  of  this  stage  should  be  compared  with  those  of  the  stage  of  incipient 
or  mild  compression. 


40  SURGICAL   AFPECTIONS    OF   THE   HEAD. 

(c)  The  pulse  is  rapid  and  weak,  corresponding  to  the  fall  in  blood- 
pressure. 

(d)  The  respirations  are  shallow  and  irregular.  Frequently  they 
are  of ,  the  Cheyne-Stokes'  type. 

(e)  Rapid  fall  in  blood-pressure. 

Many  patients  are  seen  under  one  of  the  following  conditions, 
when  the  differential  diagnosis  must  be  made  between  coma  due  to 
cerebral  compression  and  that  due  to  other  causes: 

1.  A  comatose  middle-aged  man  or  woman  is  brought  to  the  hospital 
with  the  history  of  having  fallen  on  the  street  and  sustained  a  scalp 
wound  an  hour  or  less  before  admission. 

2.  Same  condition  and  history  as  above,  but  smell  of  alcohol  in 
breath  very  marked. 

3.  Man  apparently  deeply  unconscious,  with  no  external  wound  or 
signs  of  injury,  but  with  a  history  of  having  fallen,  six  or  eight  hours 
before  examination. 

One  must  distinguish  the  symptoms  of  cerebral  compression  under 
any  or  all  of  the  above  conditions  from  the  following  forms  of  feigned 
or  genuine  coma: 

(a)  Coma  due  to  ordinary  cerebral  apoplexy. 

(b)  Uremic  coma. 

(c)  Diabetic  coma. 

(d)  Alcohohsm. 

(e)  Opium  poisoning. 

(/)  Hysterical  coma  (or  often  malingering). 

The  diagnosis  which  is  the  most  difficult  is  in  the  class  of  cases 
mentioned  under  3,  where  the  patient  has,  for  example,  been  placed  in 
the  cell  of  a  police  station  over  night,  with  the  diagnosis  of  alcoholism 
made  by  the  police  officers.  Here  the  fall  was  originally  due  to  the 
alcohol,  but  resulted  in  a  skull  fracture  with  hemorrhage,  and  the  free 
interval  between  concussion  and  compression  either  did  not  exist  or  was 
overlooked.  This  instance  is  especially  referred  to  on  account  of  the 
fallacious  teaching  that  symptoms  of  compression  are  always  preceded 
by  a  free  interval,  which  latter  is  diagnostic  of  this  condition.  Every 
case  of  coma  must  be  systematically  examined  before  a  diagnosis  is  made. 
The  average  duration  of  life  in  non-operated  cases  of  middle  meningeal 
hemorrhage  is  25  hours  (Brun),  and  this  fact  emphasizes  the  impor- 
tance of  an  early  diagnosis  of  cerebral  compression  of  traumatic  origin. 

The  differential  diagnosis  of  the  various  forms  of  intracranial  injury 
will  be  taken  up  at  the  end  of  this  section.  As  can  be  seen  from  the 
accompanying  table,  it  will  not  be  difficult  to  make  a  diagnosis  of  the 


o  o 
<  2; 
K5 


I    i+H  [/I     r 

<u  o  t-  n 

>H  Id  •'-' 

O    rt  bO 

oj  O  tn 

o  ;g  "^  iH    • 

tn   o  S  -"   "-I 

'-^    "-  O  rt  -^ 


S'> 


c  o 
o 

.Sid 

<"  &  "^ 


u    cd    3    ni 


_C    f>    O    (U 


?t3 


H  ^ 


w  2; 


kS 


2   S 
'^   g   o 

^     f     U5 


3  TJ 


u  ^ 


^    O 


-rf  3 

•r-.       bO 


s  s 


0.::i, 


go' 


«  .^ 


p  c/1 


n3 
I- 

o 
D-o' 

h 


rt    o 


.S-S 


o.d. 

^ 

fc     O 

a-i=i 

^-'d 

O  u_ 

r  ° 

c 

U-^ 

O  -tJ 

c 

<u    ra 

.=3    rC 

ir 

,,.g     _ 

bD-*-' 

3 

Ji    O 

r' 

^          O 

D-*^ 

h- 1 

IS    a 
have 
vulsi 

41 


42  SURGICAL    AFFECTIONS    OF   THE    HEAD. 

nature  of  the  coma,  if  the  patient  is  systematicahy  examined,  as  to — (a) 
the  history  preceding  the  onset,  if  obtainable,  the  condition  (b)  of  the 
pupils,  (c)  of  the  skull,  (d)  of  the  extremities  as  to  paralysis,  (e)  of  the 
pulse,  (/)  respiration,  (g)  temperature,  (h)  urine,  and  an  (i)  ophthal- 
moscopic examination  made. 

CEREBRAL  CONTUSION  OR  LACERATION. 

The  symptoms  of  actual  demonstrable  injury  of  the  brain  are  due 
either  to  punctate  or  somewhat  larger  foci  of  contusion,  which  may 
iavolve  various  areas  of  the  cortex,  the  conducting  tracts,  the  cerebel- 


-V. 


Fig.    17. — Sagittal   Section  of  Brain  in  a  Case  of  Extensive  Traumatic   Hemorrhage   into    the 

Frontal  Lobes. 

B,  Large  clot  occupying  a  cavity  in  the  frontal  lobe.     Note  the  hemorrhages  into  the  pia  arachnoid  as  seen  in 

the  sulci  along  the  upper  surface. 

lum,  the  pons,  and  the  medulla,  or  they  may  be  the  result  of  the  de- 
struction of  an  entire  lobe  or  even  hemisphere  (Fig.  17). 

Contusion  may  be  either  direct,  i.  e.,  in  close  relation  to  the  seat 
of  injury,  or  it  may  be  indirect,  at  the  end  of  the  poles  of  force  which 
start  at  the  point  of  impact. 

Evidences  of  contusion  are  usually  most  marked  at  the  base  of  the 
brain,  especially  in  the  cerebellum,  pons,  and  medulla.  Next  in  order 
of  frequency  are  the  frontal  and  temporo-sphenoidal  lobes  (Fig.  17). 
Sixty  per  cent,  of  the  deaths  in  the  first  twelve  hours  in  470  cases  of 
skull  fractures,  observed  at  the  Heidelberg  clinic  (Brun),  were  found 
to  be  due  to  contusion  of  the  brain  and  this  was  most  marked  in  the 
cerebellum. 


CEREBRAL    CONTUSION   OR   LACERATION. 


43 


Bullets,  blunt  instruments  thrust  into  the  skull,  or  the  splinters 
of  a  depressed  fracture  cause  localized  foci  of  contusion,  also  called 
laceration  of  brain  substance,  whose  symptoms  depend  primarily  upon 
the  area  involved,  i.  e.,  upon  their  degree  of  penetration.  The  symptoms 
produced  immediately  after  the  injury  do  not  differ  from  those  resulting 
from  a  non-penetrating  force. 


Fig.  i8. — View  of  Base  of  Brain  in  a  Case  of  Extensive  Traumatic  Hemorrhage  into  the  Frontal 

Lobes. 
Same  case  as  shown  in  Fig. '17.     B,  B,  Blood-clots  occupying  a  large  cavity  in  the  right  frontal  lobe. 


Contusion  or  laceration  of  the  brain  may  be  present  under  one  of 
several  different  clinical  pictures,  as  follows: 

(a)  As  generahzed  or  localized  twitchings  or  convulsions,  obscured 
from  further  recognition  by  the  symptoms  of  concussion  or  compression, 
or  a  combination  of  both  tw^itchings  and  convulsions  during  the  first 
forty-eight^  hours,  accompanied  by  pareses  or  paralysis.  After  this 
period  such  symptoms  are  due  to  infective  conditions,  such  as  mcningo- 
encephahtis  (see  page  55). 

(b)  As  early  focal  symptoms  (aphasia,  etc.)  in  cases  where  the  signs 


44  SURGICAL   AFFECTIONS    OF   THE    HEAD. 

of  concussion  or  compression  are  either  absent  or  present  only  for  a 
short  interval. 

(c)  As  late  focal  symptoms  which  show  themselves  (in  the  form 
of  pareses  or  paralyses,  etc.)  during  convalescence  from  the  immediate 
effects  of  an  injury  such  as  concussion  or  compression. 

The  diagnosis  of  the  first  of  these  three  groups  (a)  is  a  very  difficult 
one.  This  is  due  to  the  fact  that  the  symptoms  of  concussion  (loss  of 
consciousness,  slow  pulse  and  respiration,  etc.),  or  again  those  of 
compression  (very  slow  pulse  and  respiration,  deep  coma,  etc.),  may 
in  some  cases  obscure  the  clinical  picture  to  such  an  extent  that  it  is 
impossible  to  make  an  absolute  diagnosis  of  a  contusion.  One  can 
surmise  its  presence  when  twitchings  or  convulsions  accompanied  by 
pareses  or  paralyses  appear  immediately  after  the  injury.  These  are 
at  times  present  only  on  the  side  of  the  injury;  at  others  on  the  opposite 
side  of  the  body,  or  again  are  quite  generalized.  All  of  these  symptoms 
show  a  decided  irritation  of  the  cortical  centers. 

The  second  class  of  cases  (b)  is  much  easier  to  diagnose,  for  the 
reason  that  the  loss  of  consciousness  was  very  slight  or  transitory,  or 
not  even  present.  The  signs  of  brain  contusion  most  frequently  found  in 
these  cases  are  pareses  or  paralyses  of  the  face,  arm,  or  leg  of  the  side  of 
the  body  opposite  to  that  of  the  injury,  with  or  without  aphasia.  The 
aphasia  may  appear  as  an  isolated  paralysis,  and  by  some  writers  (Koenig) 
is  considered  as  one  of  the  most  characteristic  signs  of  contusion  of 
the  brain.  The  correct  interpretation  of  the  early  signs  of  focal  brain 
injury,  as  well  as  of  those  occurring  in  the  manner  described  in  class  c 
(i.  e.,  after  the  symptoms  of  concussion  or  compression  have  begun  to 
disappear)  can  be  made  only  if  we  recall  the  more  important  facts 
in  our  present  knowledge  of  cerebral  localization.  In  other  words, 
we  can  diagnose  contusion  only  from  certain  symptoms  indicating  focal 
lesions. 

Cerebral  Localization  (Figs.  19  and  20). 
I.  Ascending  Frontal  and  Ascending  Parietal  Convolutions: 

(a)  Motor  centers  for  leg  in  upper  one-fourth  of  both  convolutions. 

(&)  Motor  centers  for  arm  in  middle  two-fourths  of  both  convolutions. 

(c)  Motor  centers  for  face  in  lower  one-fourth  of  both  convolutions. 

The  total  destruction  of  the  entire  motor  region  would  result  in 
complete  and  permanent  hemiplegia  of  the  opposite  side  of  the  body, 
with  loss  of  muscular  and  stereocognostic  senses. 

Most  frequently  the  cortical  centers  are  not  completely  destroyed, 
so  that  the  paralysis  involves  only  one  or  more  of  the  centers,  and  is 


CEREBRAL   CONTUSION   OR   LACERATION. 


45 


accompanied  by  evidences  of  cerebral  irritation  from  the  contusion, 
in  the  form  of  twitchings,  convulsions,  or  contractures.  The  com- 
bination of  these  latter  irritating  symptoms  with  paresis  or  paralysis 
of  the  extremities  or  facial  muscles  is  diagnostic  of  cerebral  contusion, 
if  they  remain  after  the  compression  of  the  brain  by  a  blood-clot  or  a 


SURPAR. 


SUP,  FRONTAL 


MID.  FRONTAL. 


INF  FRONT, 


OCCIPITAL 
LOBE 


Fig.  19. — Cerebral  Localization 


depressed  fracture  is  rcHeved.  Some  partial  destruction  of  the  motor 
cortical  centers  is  often  associated  with  aphasia  and  sensory  distur- 
bances (muscle  sense),  owing  to  the  proximity  of  these  centers.  One 
of  the  following  combinations  may  occur: 

I.  Paralysis  or  clonic  convulsions,  or  both,  of  the  arm  (monoplegia 


46 


SURGICAL   AFFECTIONS    OF    THE    HEAD, 


and  monospasm).     This  is  often  accompanied  by  a   loss  of  muscle 
and  stereocognostic  senses. 

2.  Same  condition  of  leg  alone.  Less  often  than  in  the  arm  there  is 
a  loss  of  muscle  and  stereocognostic  senses.  Monoplegia,  etc.,  of  the 
leg  alone  is  not  as  frequent  as  in  the  arm. 

3.  Isolated  paralysis  of  the  face  of  cortical  origin  is  comparatively 
rare.  It  occurred  as  an  isolated  paralysis  only  eight  times  in  83  cases 
of  facial  paralysis,  out  of  a  total  of  470  cases  of  skull  injury  collected 
by  Brun. 

4.  Association  of  monoplegia  of  the  face  and  the  arm   (forearm 


Motor  region.  Contralateral  mo- 
no- or  hemiplegia  of  leg,  arm, 
and  face  from  abo\e  down- 
ward, with  or  without  spasms. 


Upper  prefrontal 
and        frontal 
convolutions. 
Psychical    dis- 
turbances. 


Upper  parietal  convolution. 
Impairment  of  muscular 
and  cutaneous  sensibility 
(astereognosis). 


Higher  \'isual 
area.  Word- 
blindness. 


Posterior  portion 
of  third  frontal. 
Motor  aphasia. 


Cerebellum. 
Cerebellar  ataxia. 


Posterior  lialf  of  tem 
poro  -  sphenoida 
lobe.  "Word-deaf 
ness. 


Pons. 

Crossed    MeduUa.  Crossed  and  nu- 
lesions.        clear  lesions. 


Fig.  20. — View  of  Left  Half  of  Brain  to  Illustrate  Principal  Sym:ptoms  in  Cases  of  Tumors  or 
Other  Focal  Lesions  (Diagramm.atic). 


muscles  predominantly  affected),  never  of  the  face  and  the  leg  (because 
the  centers  of  latter  two  are  not  adjacent). 

5.  Association  of  facial  and  tongue  (motor  aphasia)  monoplegia. 
Caution  must  be  employed  in  diagnosing  these  cases,  because  the  par- 
alysis of  the  facial  muscles  may  per  se  interfere  with  speech.  If  a  true 
faciolingual  monoplegia  exists,  the  tongue  points  to  the  paralyzed  side. 

6.  Association  of  monoplegia  of  the  arm  and  of  the  leg. 

The  paralysis  or  paresis  and  the  convulsions  of  the  muscles  of  the 
extremities  may  extend  day  by  day  from  one  motor  center  to  the  other, 
and  thus  not  all  appear  at  one  time.  If  the  paralyses  are  due  to  com- 
pression from  blood-clots,  or  a  depressed  fracture,  or  a  spHnter of  bone, 
they  disappear  as  soon  as  the  cause  is  removed.     If  the  paralyses  are 


CEREBRAL    CONTUSION    OR   LACERATION.  47 

due  to  contusion,  however,  they  disappear  either  gradually  or  become 
permanent.  If  the  latter,  they  may  be  the  beginning  of  a  Jacksonian 
epilepsy. 

II.  Parietal  Lobe. — ^Lesions  of  this  region  cause  disturbances  of 
muscle  sense.  It  has  been  impossible  up  to  the  present  time  to  exactly 
localize  the  centers  of  general  sensation  and  its  modifications,  tactile, 
muscular,  pain,  and  temperature  senses. 

III.  Frontal  Lobe. — Lesions  of  the  right  frontal  convolutions  more 
frequently  result  in  psychical  disturbances  than  do  injuries  of  the  left 
side.  These  occur  especially  in  middle-aged  patients  who  have  been 
drinkers.  Such  patients  in  the  early  days  after  an  injury  are  apt  to  be 
restless,  suffer  from  insomnia,  or  they  are  very  talkative,  or  again  are 
apathetic.  Later  on  they  suffer  from  loss  of  memory,  especially  of  the 
smaller  things  of  everyday  life,  and  are  apt  to  be  very  excitable  and 
lack  concentration  of  the  mind.  In  other  words,  lesions  of  the  frontal 
lobes  result  in  disturbances  of  the  higher  psychical  functions  with  the 
exception  of  the  motor  speech-area. 

IV.  Occipital  Lobe. — Lesions  of  this  part  of  the  brain,  including 
the  lobus  cuneus  and  lingual  lobule,  cause  bilateral  homonymous  hem- 
ianopsia, i.  e.,  loss  of  vision  in  the  temporal  one-half  of  the  field  on  the 
side  of  the  injury,  and  the  nasal  one-half  of  the  opposite  side.  Destruc- 
tion of  the  left  gyrus  angularis  causes  word-bhndness,  i.  e.,  inability 
to  see  printed  speech.  Destruction  of  both  gyri  angularis  causes  mind- 
blindness  (Seelenblindheit),  all  objects  failing  of  recognition. 

V.  Subcortical  Regions  (White  Matter). — Lesions  of  these 
portions  cause  the  same  symptoms  as  the  corresponding  portions  of 
the  cortex. 

VI.  Pons  Varolii. ^The  symptoms  of  injury  of  the  pons  depend 
upon  whether  the  lesion  is  above  or  below  the  crossing  or  decussation 
of  the  facial' fibers.  If  it  occurs  below  (lower  one-third  of  pons),  it 
will  cause  a  facial  paralysis  on  the  same,  and  a  paralysis  of  the  extrem- 
ities on  the  opposite,  side  (crossed  hemiplegia).  If  the  lesion  is  above 
the  decussation,  the  face,  arm,  and  leg  paralysis  are  on  the  same  side. 
There  is  frequently  involvement  of  .the  fifth  and  sixth  nerves. 

VII.  Speech  Region. — (a)  Motor  Aphasia. — ^The  lesion  is  in  the 
posterior  half  of  the  third  frontal  convolution  on  the  left  side.  There 
is  an  inability  to  produce  articulate  speech  spontaneously  or  from 
dictation.     Reading  (alexia)  and  writing  (agraphia)  are  impaired. 

One  must  always  be  careful  to  differentiate  a  difficulty  in  articula- 
tion due  to  paralysis  of  the  facial  muscles  from  true  motor  aphasia. 
The  latter  rarely  occurs  as  an  isolated  condition,  being  usually  associated 


48  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

with  paresis  of  the  arm  muscles.  Motor  aphasia  occurs  especially 
in  depressed  fractures  of  the  anterior  portion  of  the  left  parietal  and 
the  posterior  portion  of  the  frontal  bones.  It  generally  disappears 
in  one  and  one-half  to  two  months. 

(b)  Sensory  Aphasia  (Word-deafness). — ^The  lesion  is  in  the  first 
left  temporal  convolution.  In  this  form  the  patient  does  not  under- 
stand what  is  said  to  him.  If  the  visual  speech-center  in  the  gyrus 
angularis  is  also  affected,  there  is  also  alexia  or  inabihty  to  understand 
printed  words. 

(c)  Visual  Aphasia. — ^This  has  been  referred  to  above  (page  43). 
There  is  word-blindness  present,  i.  e.,  written  symbols,  figures,  and 
other  conventional  signs  have  lost  their  significance  (Church).  When 
the  gyrus  angularis  alone  is  affected,  there  is  word-bhndness.  When 
the  radiations  of  the  optic  fibers  from  the  basal  gangha  are  destroyed, 
there  is  hemianopsia  in  addition. 

Lesions  of  the  pons  may  also  cause  articulative  disturbances. 

VIII.  Lesions  of  the  medulla  often  cause  immediate  death  through 
paralysis  of  the  vagus  nuclei.  There  may  also  be  many  symptoms  of 
injury  to  the  medulla  should  the  patient  survive,  such  as  diabetes, 
albuminuria,  polyuria,  singultus,  bulbar  symptoms,  and  inflammatory 
conditions  of  the  lungs.  The  latter  are  the  second  most  frequent  cause 
of  death  in  the  first  days  of  the  injury,  the  most  frequent  being  contusion 
of  the  vital  centers  in  the  medulla. 

IX.  Cerebellum. — Injuries  of  this  part  of  the  brain  cause  ataxia, 
incoordination,  muscular  weakness,  nystagmus,  and  vertigo.  Irritative 
lesions  cause  muscular  stiffness  on  the  same  side  of  the  body  and 
arching  of  the  spine  (opisthotonos). 


INTRACRANIAL  HEMORRHAGE. 

In  examining  a  patient  for  the  purpose  of  making  a  diagnosis  of 
whether  an  injury  to  the  skull  or  brain  has  been  complicated  by  intra- 
cranial hemorrhage,  one  must  take  into  consideration  the  various 
sources  from  which  it  can  arise  and  their  symptoms. 

Intracranial  hemorrhage  of  traumatic  origin  can  occur  from  the 
following  vessels  in  their  order  of  frequency: 

I.  From  the  Trunk  or  One  of  the  Branches  of  the  Middle  Meningeal 
Artery. — ^This  hemorrhage  takes  place  between  the  internal  table  and 
the  outer  layer  of  the  dura  and  is  known  as  an  extradural  or  epidural 
hematoma  (Fig.  21).  It  is  usually  called  "middle  meningeal  hemor- 
rhage" in  practice.     In  many  cases  there  is  an  accompanying  laceration 


INTRACRANIAL  HEMORRHAGE. 


49 


of  the  dura,  so  that  the  blood  also  escapes  into  the  subdural  space,  caus- 
ing a  bilocular  hematoma. 

2.  From  the  Smaller  Arteries  of  the  Pia  Arachnoid. — ^The  blood 
either  remains  in  the  sulci  (Fig.  17),  beneath  the  unbroken  pia  mater, 
or  it  escapes  through  lacerations  in  this  membrane  into  the  subdural 
space  and  collects  especially  at  the  base  of  the  brain.  This  form  of 
hemorrhage  is  known  as  the  subdural  and  is  often  spoken  of  as  "inter- 
meningeal, "  because  the  blood  lies  in  the  subdural  space  between  the 
dura  mater  and  the  pia  arachnoid.     From  a  pathological  standpoint. 


Fig.  21. — Diagrammatic  Representation  of  Various  Forms  of  Intracranial  Hemorrhage. 

EDC,  Epidural  clot,  most  frequently  due  to  rupture  of  middle  meningeal;  SDC,  subdural  hemorrhage;  PB, 

hemorrhage  into  the  pia  arachnoid;  CH,  hemorrhages  into  the  cortex. 


as  was  stated  above,  there  are  many  cases  of  middle  meningeal  hem- 
orrhages in  which  the  dura  is  torn  so  that  the  blood  escapes  into  the 
subdural  space  as  well  as  into  the  epi-  or  extradural  space.  Chnicallv 
it  is  impossible  to  differentiate  such  a  bilocular  hemorrhage  from  an 
epidural  one  in  the  true  sense  of  the  word. 

3.  From  the  Venous  Sinuses. — ^Those  most  often  injured  are  the 
longitudinal,  the  lateral,  and  the  cavernous  sinuses.  Of  these,  the 
longitudinal  is  the  most  frequently  involved,  being  torn  by  a  fracture 
of  the  vertex  or  penetrated  by  a  bullet  or  some  blunt  instrument.  The 
lateral  sinus  is  injured  in  a  similar  manner,  although  cases  are  recorded 
4 


so 


SURGICAL    AFFECTIONS    OF   THE    HEAD. 


in  which  it  has  been  torn  without  an  accompanying  fracture  of  the 
skulL 

The  cavernous  sinus  is  usually  torn  in  fractures  of  the  anterior  and 
middle  fossae  of  the  base.  A  laceration  of  the  cavernous  sinus  is  com- 
paratively rare.  It  occurs  most  often  in  conjunction  with  an  injurv^ 
of  the  internal  carotid  SLvteij,  resulting  in  the  formation  of  an  arterio- 
venous aneurysm  whose  most  prominent  symptom  is  a  pulsating  exoph- 
thalmos. It  is  well  to  mention  again  that  cases  of  this  form  of  injury 
to  the  sinus  and  artery  have  occurred  without  a  fracture  of  the  base. 

4.  Injuries  of  the  Intracranial  Portion  of  the  Infernal  Carotid  and 
of  the   Vertebral  Arteries. — ^Laceration  and  escape  of  blood   into  the 

interior  of  the  skull 
may  occur  from  injury 
of  either  of  these  ves- 
sels, for  example,  as 
a  result  of  gunshot 
wounds.  Fort  u- 
nately,  however,  they 
are  of  rare  occurrence 
and  cause  death  be- 
fore a  diagnosis  can 
be  made. 

It  may  be  of  some 
interest  in  connection 
with  the  diagnosis  of 
intracranial      hemor- 
rhage   to    state    that 
Chipault,   out  of  117 
cases    of   intracranial 
hemorrhage,  found  72 
to  be  from  the  middle  meningeal  arteries  and  30  from  the  sinuses.    Treves 
beheves  that  80  to  85  per  cent,  of  all  intracranial  hemorrhages  are  due 
to  injury  of  the  middle  meningeal  artery. 

I.  Diagnosis  of  Middle  Meningeal  Hemorrhage. — As  was  stated 
on  page  36,  the  symptoms  of  middle  meningeal  hemorrhages  are  those 
of  the  cerebral  compression  which  it  produces.  We  must  watch  for 
these  in  every  case  of  cerebral  injury  in  which  either  the  patient  does 
not  recover  within  a  reasonable  period  from  the  symptoms  of  concussion 
which  appeared  immediately  after  the  injury  occurred,  or  he  becomes 
drowsy,  stuporous,  and  gradually  comatose  after  a  period  of  conscious- 
ness.    This  free  interval  may  either  follow  the  symptoms  of  concussion 


/  h 

Fig.  22. — Site  of  Trephine  Opening  to  Reach  Clot  in  Hemor- 
rhage FROM  Middle  Meningeal  Artery  (Kronlein). 
a,  6,  Horizontal  line  through  the  meatus  ;  c,  d,  on  a  line  with  the 

eyebrows ;  e,  f,  vertical  line  3  to  4  cm.  behind  the  ext.  ang.  process  ; 

g,  h,  at  the  posterior  border  of  the  mastoid  process,     a,  the  point  to 

reach  the  anterior,  and  b,  the  posterior  branch. 


INTRACR.\XIAL  HEMORRHAGE.  5 1 

or  the  latter  may  have  been  so  shght  that  the  patient  or  his  relatives 
paid  no  attention  to  them  until  those  of  compression  began  to  appear. 
According  to  some,  this  free  interval  is  absoluteh'  diagnostic  of  middle 
meningeal  hemorrhage,  and  it  is  well  to  remember  that  this  is  the  most 
typical  manner  in  which  it  occurs.  But  one  must  not  overlook  the 
fact  that  there  may  be  no  free  interval  or  that  there  is  often  no  history 
obtainable  of  such  a  period  devoid  of  symptoms  of  compression.  The 
hemorrhage  may  occur  from  the  trunk  of  the  middle  meningeal  artery 
alone,  under  which  conditions  the  hemorrhage  is  quite  profuse,  and  a 
frequently  accompanying  tear  of  the  dura  permits  the  blood  to  escape 
into  the  subdural  space  as  wtII  as  into  the  extradural.  In  general  it 
may  be  said  that  the  lower  down  the  artery  is  torn  the  more  rapidly 
do  the  symptoms  appear. 

If  either  the  anterior  or  posterior  branches  are  torn,  a  clot  forms 
at  the  corresponding  part  of  the  extradural  space,  compressing  the 
underlying  brain  (see  Fig.  21 ).  In  infants  the  blood  from  a  torn  middle 
meningeal  artery  may  escape  through  the  opening  in  the  skull  caused  by 
the  fracture  and  collect  beneath  the  scalp,  forming  an  enormous  ceph- 
alhematoma which  does  not  have  the  suture  lines  as  its  boundaries. 
Cephalhematomata  arising  during  parturition,  or  later  as  a  result, 
have  the  suture  lines  as  their  boundaries  (page  18). 

If  the  symptoms  of  compression  appear  immediately  after  the  injury, 
they  are  most  likely  due  to  a  depressed  fracture;  if  they  appear  after  a 
few  hours,  they  are  due  to  hemorrhage.  If  they  appear  after  thirty-six  to 
forty-eight  hours,  they  are  due  to  some  infective  comphcation.  The 
diagnosis  of  middle  meningeal  hemorrhage  can  be  made  from  the 
following  history:  Immediately  after  the  injur}-  the  patient  either 
becomes  unconscious  and  shows  the  signs  of  concussion  (see  page  35) 
instead  of  recovering  consciousness,  the  coma  grows  deeper,  the  respira- 
tions, instead  of  being  weak  and  slow,  become  stertorous,  the  pulse, 
which  was  of  low  tension  and  slower  than  normal,  becomes  firm,  the 
tension  greatly  increased  and  very  slow,  often  sinking  to  40  or  50.  The 
blood-pressure,  which  was  but  slightly  increased  by  the  concussion, 
becomes  quite  high.  If  the  clot  presses  on  the  so-called  silent  area  of 
the  cortex,  there  are  no  focal  symptoms,  but  if  there  is  pressure  over  the 
Rolandic  area  (Fig.  19),  there  is  a  distinct  lack  of  movement  of  the  facial 
muscles,  of  the  muscles  of  the  arm,  and  of  those  of  the  leg  on  the  side 
of  the  body  opposite  to  that  of  the  lesion,  also  called  contralateral 
monoplegia  or  hemiplegia.  The  hemiplegia  of  a  middle  meningeal 
hemorrhage  is  complete;  that  due  to  a  contusion  of  the  brain  is  only 
partial.     Both  forms  are  often  accompanied  b}'  Iwitchings  or  con\-ul- 


52 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


sions  of  the  affected  muscles,  but  this  is  more  characteristic  of  con- 
tusion. 

If  the  patient  does  not  show  the  above-mentioned  symptoms  imme- 
diately after  those  of  the  primary  concussion,  they  may  appear  after  a 
short  interval.     Again,  a  man  or  woman  may  appear  perfectly  well 

after  a  fall  on  the  head 
or  a  scalp  wound,  and 
have  been  dressed  by 
a  physician  who  has 
made  a  diagnosis  of 
fissured  fracture  of 
the  vertex  or  of  frac- 
ture of  the  base  with- 
out complications.  A 
few  hours  later  the 
patients  become  irri- 
table and  restless,  the 
pulse  becomes  slower, 
they  cannot  be 
aroused,  and  the 
typical  symptoms  of 
compression  appear. 
In  addition  to  these 
general      and      focal 

i«  brain    symptoms   one 

.  •  f  can   often  find  as  an 

aid  to  the  diagnosis 
a  tenderness,  or  a 
hematoma,  or  at 
times  an  ecchymosis 
over  the  temporal 
bone  on  the  same 
side  as  the  intra- 
cranial hemorrhage. 
The  latter  signs  are 
due  to  the  escape  of  blood  through  the  gap  in  the  bone. 

2.  The  diagnosis  of  an  intermeningeal  or  subdural  hemorrhage 
in  children  and  adults  cannot  be  made  with  any  degree  of  exactness. 
In  general  it  may  be  said  that  the  symptoms  of  compression  are  much 
less  marked  than  in  middle  meningeal  hemorrhage,  and  are  slower  in 
onset.     In  some  cases  lumbar  puncture  has  been  performed  and  the 


Fig.  23. — First  Step  in  Determining  the  Point  to  Make  a 
Lumbar  Puncture. 
C,  C,  Tape-measure  resting  upon  highest  point  of  the  crests  of 
the  ilia;  P,  P,  posterior  superior  spines  of  the  ilia;  III,  IV,  and  V, 
spines  of  the  third,  fourth,  and  fifth  lumbar  vertebra;;.  L,  L,  indicate 
two  points  lateral  to  the  median  line  of  the  spine  in  third  interspace, 
where  needle  is  usually  inserted. 


INTRACRANIAL  HEMORRHAGE. 


53 


cerebrospinal  fluid  thus  withdrawn  found  deeply  stained  by  blood 
(Figs.  23,  24).  This  means  of  diagnosis  need,  however,  seldom  be 
resorted  to.  In  subdural  hemorrhages  cortical  centers  quite  widely 
separated  are  often  involved.  The  temperature  is  more  uniformly 
high.  If  the  hemorrhage  occurs  chiefly  into  the  pia  arachnoid  and 
into  the  cortex,  the  symptoms,  such  as  convulsions,  cannot  be  easily 
distinguished  from  those 
of  contusion,  although  the 
convulsions  are  more  apt 
to  be  unilateral  in  a  hemor- 
rhage. In  newborn  in- 
fants subdural  and  pial 
hemorrhages  cause  tense 
fontanelles,  asphyxia,  and 
convulsions.  These  may 
not  appear  until  several 
days  after  birth. 

3.  Hemorrhage  from 
the  Venous  Sinuses. — Of 
the  three  principal  vari- 
eties of  traumatic  intra- 
cranial hemorrhage,  that 
from  the  sinuses  causes  the 
least  degree  of  compres- 
sion and  can  be  recognized 
from  the  extreme  slowness 
of  the  onset  of  the  symp- 
toms. The  diagnosis  de- 
pends upon  the  situation 
of  the  wound  or  fracture, 
upon  the  mild  compres- 
sion symptoms,  and  in  the 
case  of  the  longitudinal 
sinus,  upon  the  escape  of 
considerable    blood    from 

a  wound  in  close  proximity  to  the  sinus.   "  Focal  symptoms  are  usually 
absent. 

Hemorrhage  from  the  intracranial  portion   of  the  internal  carotid 
causes  almost  immediate  death. 

4.  Late   Traumatic  Apoplexy. — A  number  of    cases  have  been 
reported  in  which  symptoms  of  cerebral  apoplexy  have  appeared  after  a 


Fig.  24. — Method  of  Performing  Lumbar  Puncture. 
P,  Posterior  superior  spines  of  the  ilia;  C,  uppermost  level 
of  crest  of  ilium;  III,  spine  of  third  lumbar  vertebra;  tV, 
spine  of  fourth  lumbar  vertebra;  V,  spine  of  lifth  lumbar  ver- 
tebra. The  needle  is  directed  to  the  third  lumbar  interspace, 
a  little  lateral  to  the  median  line.     (See  text.) 


54 


SURGICAL   AFFECTIONS    OF.  THE    HEAD. 


clear  interval  of  days  to  weeks,  the  longest  period  being  four  weeks 
(Stadelmann)  after  an  injury  to  the  head.  The  question  of  whether 
these  are  due  to  trauma  has  come  to  be  of  considerable  medicolegal 
interest.  The  symptoms  of  compression  are  the  same  as  those  due  to 
extra-  or  subdural  hemorrhage,  the  only  difference  being  that  the  clot 
lies  beneath  the  cortex,  either  in  the  white  matter  or  in  the  internal 
capsule. 

The  question  arises,  Can  these  late  hemorrhages  be  ascribed  to  the 
injury  ?  A  number  of  articles^  have  recently  appeared,  and  the  majority 
of  writers  believe  that  the  injury  merely  plays  the  part  of  an  exciting 
cause  in  a  person  predisposed  by  reason  of  some  vascular  weakness 
due  to  alcoholism,  nephritis,  syphilis,  or  cardiac  disease. 


DIFFERENTIAL  DIAGNOSIS  OF  INJURIES  OF  THE  BRAIN. 


Concussion. 
Time  of  onset 

of  symptoms.. Immediately   after   ac- 
cident. 


General  cerebral 

symptoms  '. .  .  Loss  of  consciousness 
for  some  minutes 
to  hours.  Vomit- 
ing. 


Focal  symptoms.. -None,  unless  compli- 
cated by  contusion 
or  compression  or 
injury  to  cranial 
nerves . 

Pulse Slower    than    normal. 

No  increase  in  ten- 
sion. 


Respiration Slower  than  normal. 


Blood-pressure  ...Slight  rise. 

Pupils  and  eyeball.  May  be  dilated  or  con- 
tracted. 


Temperature No  change. 

Lumbar  puncture. Negative. 
Variety  of  force Usually  diffuse. 


Course. 


.  Symptoms  gradually 
decrease  and  re- 
covery, or  symp- 
toms of  contusion 
or  compression  ap- 
pear, or  death  en- 
sues. 


Contusion. 

Immediate,  but  are  usually 
obscured  by  those  of 
concussion  or  com- 
pression. 

Unconscious  if  complicated 
by  concussion  or  com- 
pression. 


Localized  or  general  twitch- 
ings  and  convulsions, 
accompanied  by  pareses 
or  paralyses. 

No  change,  unless  medulla 
affected,  then  indistin- 
guishable from  par- 
alytic stage  of  concus- 
sion and  compression 
except  by  earlier  onset 
of  rapid  feeble  pulse. 

Same  as  above  true  for  res- 
piration. 

No  change. 

No  change  unless  occipital 
lobe  involved  (homon- 
ymous hemianopsia). 

No  change. 

Negative. 

After  circumscribed  variety. 


Signs    of    localized    injury 
usually    disappear. 
_    Very  few  become  per- 
manent. 


Compression. 

After  free  interval,  unless  due  to 
depressed  fracture.  (See 
page  36.) 


Restlessness,  apathy,  stupor 
gradually  changing  to  deep 
coma  in  hemorrhage.  Im- 
mediate unconsciousness  in 
majority  of  depressed  frac- 
tures. 

Locahzed  (face  or  arm  or  leg) 
twitchings  and  convulsions 
precede  paralysis  (usually 
in  form  of  mono-  or  hemiple- 
gia). 

Slow  (40  to  60)  and  of  high  ten- 
sion. 


Slower  and  deeper  (stertorous). 
May  be  of  Cheyne-Stokes 
type. 

Gradual  rise  as  intracranial 
tension  increases. 

Pupils  usually  unequal.  Di- 
lated on  side  of  injury,  with 
conjugate  deviation  of  eye- 
ball.    Choked  disc. 

Usually  rises  as  pressure  in- 
creases. 

Blood,  if  intermeningeal  hemor- 
rhage. 

Diffuse  in  hemorrhage  (ex- 
tension of  fissure  to  base). 
Circumscribed  in  depressed 
fractures. 

Coma,  etc.,  increase,  and  par- 
alytic stage  sets  in  unless 
relieved. 


'  Colley,  " Deutsche Zeitschrift  flir  Chirurgie,"  Vol.  69;  Marie,  "Revue  de  Medecine,"' 
May  10,  1905. 


PACHYMENINGITIS   H.^MORRHAGICA    INTERNA.  55 

PACHYMENINGITIS  H.EMORRHAGICA  INTERNA. 

This  condition  not  infrequently  follows  an  injury  to  the  head  in 
adults,  as  well  as  in  children.  In  the  former  it  occurs  especially  in 
alcohoHcs,  and  more  particularly  in  middle-aged  or  older  men.  In  a 
typical  case  one  can  get  the  history  of  an  injury,  followed  by  attacks  of 
coma  and  paralysis,  wiiich  entirely  disappear,  but  recur  after  a  variable 
interval  of  time.  During  these  attacks  the  patient  complains  of  head- 
ache, is  drowsy,  and  soon  becomes  comatose.  There  is  paralysis  of 
one  or  both  sides  of  the  body,  accompanied  by  exaggeration  of  the  tendon 
reflexes,  contractures,  and  clonic  or  tonic  convulsions.  The  pupils 
are  normal,  or  are  contracted  on  one  or  both  sides.  In  the  interval 
between  the  attacks  the  patients  usually  complain  of  vertigo,  are  easily 
fatigued,  show  psychical  disturbances,  such  as  apathy  and  loss  of  memory, 
and  there  are  evidences  of  pareses  and  paresthesia. 

The  differential  diagnosis  must  be  made  from  purulent  leptomen- 
ingitis, in  which  there  is  stupor  followed  by  coma,  ocular  paralysis, 
unequal  pupils,  and  rigidity  of  the  neck.  There  is  also  always  fever 
present,  as  well  as  a  rapid  pulse,  which  is  not  true  of  pachymeningitis 
heemorrhagica,  unless  there  is  an  accompanying  pneumonia.  Further- 
more, lumbar  puncture  shows  the  presence  of  pus  in  purulent  lep- 
tomeningitis. 

From  sinus  thrombosis  it  can  be  differentiated  by  the  presence  of  a 
cause  for  the  thrombosis,  and  repeated  chills,  followed  by  rises  of  tem- 
perature, sweats,  and  early  evidences  of  metastases. 

From  intracerebral  hemorrhage  it  is  almost  impossible  to  make  a 
diagnosis  during  the  attack,  except  that  there  is  greater  restlessness  and 
dehrium  in  pachymeningitis  haemorrhagica.  The  presence  of  epilep- 
tiform convulsions  and  contractures  and  the  recurrence  at  intervals 
speak  for  pachymeningitis  haemorrhagica. 

It  can  be  differentiated  from  tumors  of  the  brain  by  the  presence  of 
more  circumscribed  headache  and  marked  choked  disc,  as  well  as  more 
marked  focal  symptoms  in.  a  tumor. 

From  abscess  of  the  brain  it  can  be  distinguished  by  the  etiology 
and  the  more  frequent  presence  of  u  choked  disc  in  abscess. 


INTRACRANIAL  SUPPURATION  FOLLOWING  INJURIES. 

The  symptoms  of  infection  usually  appear  within  thirty-six  to  forty- 
eight  hours  after  the  injury.  This  is  the  case  with  infections  of  the 
meninges,  while  those  of  the  brain  proper  and  of  the  venous  sinuses  a})pear  a 


56  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

little  later.  Symptoms  of  infection  may,  however,  not  show  themselves  in 
the  form  of  a  circumscribed  abscess  of  the  brain  until  years  have  elapsed, 
and  under  these  conditions  the  relationship  between  the  injury  and 
the  cerebral  abscess  may  be  diificult  to  trace. 

I.  Epidural  Abscess  or  Purulent  Pachymeningitis. — The 
symptoms  of  a  circumscribed  collection  of  pus  lying  between  the  dura 
and  the  skull  do  not  differ  from  those  which  are  observed  in  cases 
where  the  pus  hes  in  the  subdural  space,  and  their  diagnosis  will  be 
considered  in  conjunction  with  the  latter  form.  The  only  difference 
between  the  epidural  and  subdural  abscesses  is  that  in  the  former 
the  external  wound  is  much  more  apt  to  present  the  evidences  of  an 
acute  infection  in  the  shape  of  swelHng,  redness,  and  tenderness  of  the 
scalp,  foul  odor  of  the  pus,  and  unhealthy  appearing  granulation-tissue. 
Such  circumscribed  collections  of  pus,  in  either  the  epi-  or  subdural 
space,  most  frequently  comphcate  fractures  of  the  vertex,  especially 
of  the  depressed  or  punctured  variety.  Basal  fractures  are  more  often 
followed  by  meningitis  of  a  diffuse  character.  In  this  connection  it 
may  be  stated  that  the  more  circumscribed  the  collection  of  pus,  the 
greater  the  possibility  of  making  a  diagnosis  from  the  focal  symptoms. 
Epidural  abscesses  occurring  from  causes  other  than  trauma,  such  as 
osteomyelitis  of  the  cranial  bones,  infections  from  the  frontal,  sphenoidal, 
or  ethmoidal  sinuses,  and  from  middle  ear,  and  mastoid  disease,  differ 
only  in  their  history  from  the  traumatic  variety. 

II.  Subdural  Suppuration  or  Purulent  Leptomeningitis. — On 
account  of  the  frequent  involvement  of  the  superficial  portion  of  the 
brain  in  suppurative  inflammation  of  the  pia  arachnoid,  this  form  of 
infection  has  been  given  the  name,  by  some  writers,  of  meningoenceph- 
aHtis  (Koenig),  and  by  others,  of  traumatic  meningitis  (von  Bergmann). 
Subdural  suppuration  may  occur  in  either  a  circumscribed  or  dift'use 
form.  As  is  stated  above,  the  localized  form  is  more  apt  to  follow  frac- 
tures of  the  vertex  and  give  rise  to  focal  symptoms,  but  both  the  cir- 
cumscribed and  diffuse  forms  are  likely  to  follow  fractures  of  the  base. 

The  diagnosis  of  an  infection  of  the  pia  arachnoid  following  injury 
depends  upon  the  recognition  of  certain  s3'mptoms  of  cerebral  irritation, 
followed  by  those  of  coma.  This  condition  of  leptomeningitis  should 
be  suspected  in  every  case  of  compound  fracture,  either  of  the  base  or 
vertex,  but  especially  of  the  former,  when  the  symptoms  of  concussion, 
contusion,  and  compression  having  either  disappeared  or  improved 
the  patient  begins  to  complain  of  persistent  headaclie,  or  is  delirious,  rest- 
less, drowsy,  with  rapid  pulse,  contracted  pupils,  and  a  gradually  rising 
temperature  of  a  continuous  type.     There  may  also  be  nausea  and 


INTRACRANIAL    SUPPURATION   FOLLOWING    INJURIES.  57 

vomiting  of  the  projectile  variety.  At  the  same  time,  there  are  certain 
local  signs  of  wound  infection,  such  as  abundant  secretion  of  pus  and 
angry  appearance  of  the  edges.  Within  a  few  hours  this  first  or  stage 
of  cerebral  irritation  is  followed  by  the  second  or  paralytic  stage.  Aside 
from  the  presence  of  fever  and  the  appearance  of  the  wound,  the 
symptoms  in  the  first  or  stage  of  irritation  are  somewhat  similar  to  those 
of  the  stage  of  reaction  in  concussion  cases,  which  occurs  at  about  the 
same  period  after  the  injury — thirty-six  to  forty-eight  hours.  The 
rapid  rise  of  the  pulse- rate  (80  to  100)  the  gradual  rise  of  blood-pressure, 
the  presence  of  fever  (loi  to  103°),  and  the  severity  of  the  headache, 
are  quite  characteristic  of  a  meningeal  infection.  The  second  stage 
soon  clears  up  any  doubts.  The  patient  gradually  becomes  comatose, 
and  there  are  signs  of  a  marked  increase  in  the  intracranial  tension. 

The  irritation  of  the  cortex  by  the  accumulation  of  pus  either  in  the 
subdural  space  or  meshes  of  the  pia  arachnoid  shows  itself  in  the  form 
of  localized  or  generalized  muscular  twitchings  accompanied  by  tonic 
and  clonic  convulsions. 

Pressure  on  the  cortex  causes  paralyses  of  the  face,  arm  and  leg  or 
monoplegias  according  to  the  area  affected  (Figs.  19  and  20). 

When  the  accumulation  of  pus  is  especially  marked  at  the  base  of 
the  brain,  as  happens  most  frequently  after  basal  fractures,  there  are 
scarcely  any  cortical  symptoms.  Early  rigidity  of  the  neck,  evidences 
of  pressure  on  the  cranial  nerves  at  the  base,  such  as  strabismus  and 
disturbances  of  respiration,  like  the  earher  appearance  of  the  Cheyne- 
Stokes  type  of  breathing,  lead  one  to  suspect  the  predominance  of  a 
basal  meningitis.  The  respiration  is  rapid  as  a  rule,  unless  the  infection 
involves  the  cerebellar  fossa.  The  temperature  is  of  the  continuous 
type. 

True  optic  neuritis  with  choked  disc,  gradual  rise  in  the  blood- 
pressure  as  the  pus  accumulates,  slow,  high-tension  pulse,  and  slow, 
often  irregular,  respiration,  through  stimulation  of  the  vagus,  are  all 
characteristic  of  this  second  or  paralytic  stage  of  meningeal  infection. 

The  condition  of  the  wound  in  cases  of  fracture  of  the  vertex  is 
similar  to  that  described  above  in  the  initial  stage  of  the  infection.  Not 
infrequently  there  is  a  prolapse  of  the  brain  (secondary  hernia  cerebri) 
as  a  result  of  the  increased  intracranial  tension,  through  the  opening 
in  the  vertex  (see  page  62). 

In  some  cases,  lumbar  puncture  has  been  resorted  to;  the  presence 
of  pus  in  the  spinal  fluid  confirming  the  diagnosis  of  a  leptomeningitis. 

III.  Abscess  of  the  Brain. — ^This  variety  of  intracranial  infection 
is  far  more  frequent  after  fractures  of  the  vertex  than  after  those  of  the 


58  'SURGICAL   AFFECTIONS    OF   THE    HEAD. 

base.  The  abscess  is  found  close  to  the  most  frequent  seat  of  fracture, 
hence  close  to  the  parietal  bones.  ]\IcEwen  has  sho^^^l  that  abscess  of 
the  brain,  whether  following  a  compound  fracture  or  occurring  as  a 
complication  of  middle  ear  disease,  or  from  any  cause  other  than  metas- 
tasis from  pulmonary  conditions,  is  always  contiguous  to  the  atrium  of 
infection.  About  25  per  cent,  of  all  brain  abscesses  are  the  result  of 
trauma. 

Posttraumatic  abscess  of  the  brain  may  occur  either  in  an  acute 
form,  that  is,  within  iive  to  six  days  after  the  injury,  or  in  a  chronic  form. 
In  the  latter,  the  symptoms  may  not  show  themselves  until  years  after 
the  injury.  The  symptoms  of  both  forms  are  the  same,  the  only  differ- 
ence being  in  their  time  of  appearance. 

The  diagnosis  0}  acute  traumatic  abscess  depends  upon  the  appear- 
ance of  certain  general  and  focal  signs  of  infection  which  begin  at  the 
end  of  the  first  week  following  the  injury.  The  general  signs  are  (i) 
great  mental  depression  or  irritabihty  accompanied  by  severe  headache; 
this  is  followed  by  stupor  and  coma;  (2)  local  tenderness  on  tapping 
the  skull  over  the  seat  of  the  injury;  (3)  slow  pulse  and  respiration,  the 
pulse  sinking  to  60  or  lower.  The  respiration  may  be  irregular,  even 
Cheyne-Stokes  in  character.  This  latter  type  is  especially  hkely  to 
be  the  case  in  abscesses  of  the  cerebellum.  (4)  PapiUitis  and  choked 
disc  are  not  constantly  present.  Their  absence  will  not  exclude  the 
presence  of  a  cerebral  abscess.  (5)  The  temperature  is  either  normal 
or  subnormal.  (6)  Focal  symptoms — these  will  vary  according  to  the 
location  of  the  lesions  and  consist  of  convulsions  and  paralysis,  or 
symptoms  of  aphasia,  etc.  There  may  be  locahzed  twitchings  with 
convulsions  of  the  muscles  of  one  extremity  or  of  the  entire  opposite 
half  of  the  body.  The  extent  of  the  paralysis  is  not  always  a  criterion  of 
the  amount  of  destruction  of  the  cerebral  tissue,  owing  to  the  fact  that 
many  symptoms  both  of  irritation  and  paralysis  are  due  to  inflammatory 
edema  in  the  neighborhood  of  the  focus  of  suppuration  called  by  German 
surgeons  "Femwirkung."  Aphasia  may  be  present  in  connection  with 
the  paralysis  of  the  extremities,  although  this  is  less  frequent  after 
traumatic  than  after  otitic  infection.  ■  In  abscesses  of  the  cerebellum 
there  are,  in  contradistinction  to  those  of  the  cerebrum,  a  few  more 
distinctly  locahzing  sympto.ms.  These  are  rigidity  of  the  neck,  occipital 
headache,  cerebellar  ataxia,  and  at  times  marked  vertigo  and  vomiting. 
(7)  The  appearance  of  the  wound — there  is  an  increased  amount  of 
suppuration  from  the  wound,  the  edges  look  angry,  and  the  granulation- 
tissue  edematous. 

The  difjerential  diagnosis   of  an  acute  traumatic  abscess,  must  be 


INTRACRANIAL    SUPPURATION    FOLLOWING    INJURIES.  59 

made  from  the  following:  (a)  From  epidural  abscess,  in  which  the 
general  pressure  symptoms  are  far  less  marked, — there  are  no  focal 
symptoms  as  a  rule  and  the  temperature  is  usually  higher;  (b)  from  a 
purulent  leptomeningitis, — the  differentiation  cannot  be  made  for  the 
reason  that  the  symptoms  of  the  meningitis  usually  obscure  those  of  the 
abscess;  (c)  from  sinus  thrombosis, — this  form  of  infection  is  compara- 
tively rare  after  fractures  of  the  skull,  usually  involving  only  the  longi- 
tudinal sinus.  A  septic  sinus  thrombosis  can  be  distinguished  readily 
from  cerebral  abscess  by  the  frequent  occurrence  of  chills  followed  by 
the  characteristic  steeple-like  rise  of  temperature  and  followed  by  sweats 
as  well  as  by  the  evidences  of  pulmonary  metastasis. 

The  chronic  traumatic  abscess  can  only  be  distinguished  from 
abscesses  of  the  brain  due  to  other  causes  by  the  history  of  a  preceding 
trauma  sufficient  to  permit  of  the  invasion  of  the  interior  of  the  cranium 
by  microorganisms.  Often  the  only  symptoms  observed  at  the  time 
of  injury  are  those  of  cerebral  contusion,  from  which  the  patient  fully 
recovers.  After  a  long  period  of  latency  in  which  apathy,  melancholia, 
headache,  and  emaciation  are  present,  three  groups  of  symptoms  begin 
to  show  themselves;  (a)  those  due  to  the  infection,  such  as  shght  rise  of 
temperature,  lack  of  appetite,  muscular  weakness,  etc.;  {b)  the  signs  of 
increased  intracranial  pressure,  such  as  mental  depression  or  irritability, 
headache,  increased  by  exertion  or  upon  tapping  the  skull  over  the  seat 
of  the  abscess,  vomiting,  stupor  and  choked  disc,  slow  pulse,  and  increase 
of  blood-pressure.  Choked  disc  is  less  constant  in  an  abscess  of  the 
brain  than  in  tumor;  (c)  the  focal  symptoms,  which  vary  according  to  the 
seat  of  the  abscess  in  the  same  manner  as  in  the  acute  form  and  consist 
of  general  or  locahzed  epileptiform  convulsions,  hemiplegia,  and  similar 
focal  signs. 

The  differential  diagnosis  of  chronic  traumatic  abscess  must  be 
made  principally  from  tumor  of  the  brain  (see  page  80). 

Sinus  'Thrombosis. — Infective  thrombosis  of  the  intracranial 
sinuses  is  comparati\-cly  rare  after  injury  to  the  scalp  or  skull.  It  can 
occur  after  erysipelas  or  phlegmon  of  the  scalp,  following  infected 
wounds  of  the  scalp,  or  compound  depressed  or  punctured  fractures  of 
the  vertex.  The  sinus  most  frequently  affected  after  injury  is  the 
longitudinal. 

The  diagnosis  can  be  made,  first,  by  considering  the  nature  and 
position  of  the  injury  and,  second,  the  possibihty  of  infection  having 
traveled  either  by  way  of  the  lymphatics  or  veins,  through  the  skull  into 
the  sinuses.  The  manner  in  which  this  occurs  can  be  readily  under- 
stood by  a  reference  to  Fig.  25,  which  shows  how  infection  of  the  super- 


6o 


SURGICAL    AFFECTIONS    OF    THE    HEAD. 


ficial  veins  of  the  scalp  or  skull  can  by  progression  of  the  thrombotic 
process  be  transmitted  to  the  sinuses  into  which  these  veins  empty. 

The  second  point  in  diagnosis  is  to  obsen^e  the  local  signs  of  infection 
of  particular  sinuses.  This  is  fully  considered  on  page  85,  in  connec- 
tion with  otitic  sinus  thrombosis. 

Thirdly,  the  general  evidences  of  infection,  usually  of  a  pyemic 


Fig.  25. — Modes  of  Traxsmission  of  Infective  Thrombosis  Along  the  Exdocraxial  Sixuses. 
SOL,  Superior  longitudinal  sinus;  PE,  parietal  emissary  vein;  55,  sigmoid  sinus.  The  white  arrows  point 
to  the  three  directions  in  which  infection  may  be  transmitted  from  this  sinus  along  the  superior  petrosal  {SP), 
the  inferior  petrosal  {IP),  and  internal  jugular  {If).  MV,  Mastoid  emissary  vein,  along  which  infection  may 
be  transmitted  in  the  direction  of  the  black,  arrow  to  sigmoid  sinus;  CS,  cavernous  sinus.  The  white  arrow 
shows  the  direction  of  transmission  of  infection  from  the  pterygoid  plexus  of  veins  {PP),  and  ophthalmic  vein 
(.OV).  FC,  Vein  passing  through  foramen  cecum  into  longitudinal  sinus;  FF,  communication  of  facial  {FV) 
and  veins  of  upper  lip  (5i), 'n'ith  ophthalmic  vein  and  cavernous  sinus;  AF,  anterior  facial  vein;  C,  com- 
.munication  between  the  external  and  internal  jugular  veins. 


character.  The  pulse  is  rapid.  The  temperature  is  of  a  remittent 
type,  severe  chills  occur  at  irregular  intervals,  followed  by  high  tempera- 
tures and  sweats.  The  patient  usually  suffers  from  severe  headache, 
either  diffuse  or  circumscribed.  The  mind  is  clear  unless  there  is  a 
complicating  meningitis  or  abscess. 

The  spleen  is  frequently  enlarged,  and  following  every  chill  there  are 
evidences  of  fresh  metastases.     The  majority  of  the  latter  arc  pulmonary, 


CONTUSIONS    OF   THE    CIL^NIAL    BONES. 


6l 


in  the  form  of  miliary  or  somewhat  larger  abscesses  which  give  rise  to  the 
symptoms  of  pleurisy  or,  if  they  break  into  the  pleura,  of  pyopneumo- 
thorax. 

There  is  a  second  chnical  type  of  thrombosis  knoTvn  as  the  typhoid 
or  septicemic  form.  It  occurs  more  frequently  after  sinus  thrombosis 
compKcating  middle  ear  disease  and  will  be  referred  to  later  (page  84). 


DIFFERENTIAL    DIAGNOSIS   OF    INTRACR.\XIAL    INFECTION  FOLLOW- 
ING INJURY. 


Mexixgitis. 

Time  of  onset 

of  symptoms..  Thirty-sLx     to     forty-eight 
hours  after  injury. 


General  cerebral 

sjTnptoms Severe  headache,  delirimn, 

restlessness,  stupor  grad- 
ually changing  to  coma. 
!May  have  nausea  and 
vomiting. 

Focal  sj-mptoms..  .Localized  and  generalized 
(more  marked)  twitch- 
ings  and  convulsions  if 
on  convexity.  Paralysis 
of  cranial  nerves  es- 
pecially ocular  and  facial 
if  basal  (see  page  28). 


Temperature High  and  usually  of  con- 
tinuous type.     (101-103° 

F-) 

Pulse Rises  as  symptoms  mcrease, 

usually  is  80  to  100. 

Respiration At  first  more  rapid  than  nor- 
mal but  becomes  slower 
as  e.vudate  increases  and 
again  faster  during  ter- 
minal or  paralytic  stage. 

Blood-pressure Rises  gradually  as  exudate 

increases. 

Eyes Paralyses  of  ocular  muscles 

especially  marked  in  basal 
meningitis.  (Ptosis,  di- 
lated pupils,  strabismus, 
etc.)  Rarely  have  optic 
neuritis  or  choked  disc. 

Lumbar  punc- 
ture  ^Turbid  fluid. 

Condition     of 

wound If  on  convexity  granulations 

edematous,  wound  edges 
swollen,  reddened,  tender 
and  often  necrotic. 

Course Death  in  a  short  time  (i  to  2 

weeks)  after  onset. 


Cerebral  Abscess. 

Either  toward  the  end  of  the  first 
week  (early  or  acute)  or  after 
some  months  or  years  (late 
or  chronic  form) . 

Headache  often  more  localized 
than  in  meningitis.  Drowsi- 
ness followed  by  coma. 


Majority  of  the  posttraumatic 
abscesses  close  to  motor  region , 
hence  localized  t^vitchings  and 
parah'sis  of  mono-  or  hemi- 
plegic  type.  Often  speech 
and  visual  disturbances. 
(Distant  action.)  All  focal 
symptoms  more  marked  than 
in  meningitis. 

Very  slightly  above  normal. 


Becomes  slower  as  abscess  forms. 


Slower,   often  irregular  and  of 
ChejTie-Stokes  type. 


Marked  rise  as  intracranial  ten- 
sion increases. 

Depends  on  location.  If  close 
to  occipital  lobe  (homonymous 
hemianopsia).  Optic  neuritis 
and  choked  disc  seldom  well 
marked. 


Negative. 

Same  as  in  meningitis,  consider- 
able pus  discharged  from 
wound. 

Recovery  in  majority  if  operated 
on  and  no  compUcating  sinus 
thrombosis  or  meningitis. 
If  not  operated  pus  escapes 
into  ventricles  or  subdural 
space. 


SiXUS    THROiTBOSIS. 

Usually  toward  end  of 
first  week. 


Clouded  mental  con- 
dition, but  brighter 
than  in  meningitis  or 
abscess  unless  these 
are  present. 

No  cerebral  focal  sjTnp- 
toms. For  local 
signs  of  thrombosis 
of  indiN^dual  sinuses 
seepage  85. 


Irregular  chills  fol- 
lowed by  very  high 
fever  and  sweats. 

More  rapid  than  in  ab- 
scess, rises  greatly 
during  and  after 
chills  and  as  disease 
progresses. 

Becomes  quite  rapid  as 
e\"idences  of  pulmo- 
nary metastases  be- 
gin to  show  them- 
selves. 

SHght  rise. 

Rarely  any  changes  in 
eye  except  in  caver- 
nous sinus  throm- 
bosis. . 


Negative. 

Same  as  in  meningitis. 


Death     from     pulmo- 
nary complications. 


CONTUSIONS  OF  THE  CRANIAL  BONES. 

These,  Uke  fractures,  may  be  either  simple  of  compound.  The 
diagnosis  of  their  presence  in  either  case  can  be  made  only  from  inspec- 
tion of  the  wound  and  from  the  presence  of  intracranial  injury  without 
fracture  of  the  skull.  Their  occasional  resemblance  to  a  fracture  if 
filled  with  dirt  or  hair  has  been  referred  to  on  page  25. 


62 


SURGICAL    AFFECTIONS    OF    THE    HEAD. 


HERNIA  CEREBRI. 

Hernia  cerebri  is  the  term  given  to  a  prolapse  of  the  brain  which 
may  either  immediately  follow  an  injury  or  be  the  result  of  greatly 
increased  intracranial  pressure,  such  as  (a)  occurs  from  infection  of  the 
meninges  or  brain  following  an  injury,  or  (b)  the  presence  of  a  tumor 
within  the  cranial  cavity. 

The  diagnosis  of  a  primary  hernia  cerebri  can  be  made  from  the 
protrusion,  through  a  wound  in  the  skull,  of  brain  substance.  If  there 
is  any  question  at  the  time  of  injury  as  to  whether  the  protruding  sub- 
stance is  brain,  an  examination  of  the  material  will  show  ganghon  cells. 

The  diagnosis  of  a 
secondary  hernia  cerebri 
(Fig.  26)  can  be  made 
from  the  presence  of  a  soft 
mass  which  protrudes 
through  the  gap  in  the 
skull  and  pulsates  syn- 
chronously with  the  heart. 
It  is  irregular  and  red  or 
dark  in  color.  After  a 
short  period  the  surface 
becomes  necrotic,  of  a 
grayish  color,  has  a  foul 
odor,  and  bleeds  easily,  so 
that  after  a  few  days  all 
of  the  brain  tissue  has 
•  sloughed     away,     leaving 

simply  a  bleeding  mass  of  granulation-tissue.     Pressure  on  this   soft 
tumor  causes  symptoms  of  intracranial  pressure. 


Fig.  26. — Secondary  Hernia  Cerebri  Following  Com- 
pound Fracture  of  the  Frontal  Bone  in  a  Boy  of 
Eight. 


TRAUMATIC  EPILEPSY. 
The  diagnosis  of  traumatic  epilepsy  depends  upon  a  careful  analysis 
of  the  following  factors:  First,  an  accurate  history  of  a  recent  or  old 
trauma  to  the  skull;  second,  the  objective  examination  of  the  scalp  and 
skull  for  evidences  of  the  injury — this  is  best  conducted  when  the  scalp 
is  shaven,  and  in  all  doubtful  cases  this  should  be  done;  third,  a  careful 
study  should  be  made  of  the  mode  of  onset,  of  the  form  of  the  t\vitchings 
or  convulsions,  whether  tonic  or  clonic  in  character,  and  of  the  dis- 
tribution of  the  twitchings  or  spasms;  fourth,  every  effort  should  ])C  made 


TRAUMATIC    EPILEPSY.  63 

to  exclude  the  possibility  of  the  epileptiform  seizures  being  of  the  non- 
traumatic variety. 

In  connection  with  the  first  factor,  one  should  ascertain  as  closely 
as  possible  the  symptoms  following  the  injury  which  has  been  suspected 
to  have  produced  the  epilepsy.  In  many  cases  one  can  get  a  history  of  a 
compound  fracture,  frecjuently  of  the  depressed  variety,  in  which  after 
relieving  the  depression  the  fr-agments  were  replaced. 

Again  one  can  secure  the  history  of  symptoms  of  intracranial  injury 
severe  enough  to  have  been  produced  by  a  fracture  of  the  skull,  in  which 
no  operative  interference  took  place,  so  that  it  is  proper  to  assume  that 
the  epileptiform  convulsions  are  due  to  a  non-corrected  depressed 
fracture.  This  latter  conclusion  is  corroborated  if  the  objective  ex- 
amination of  the  scalp  shows  a  distinct  depression  at  the  site  of  injury. 

One  should  always  examine  the  scalp  and  skull  for  scars  and  for 
areas  of  depression  in  the  skull.  The  absence  of  scars  or  depressions 
in  the  skull  does  not  exclude  the  possibility  of  the  epileptiform  seizures 
being  due  to  an  injury,  since  traumatic  epilepsy  follows  non-depressed 
fractures  as  frequently  as  it  does  depressed  ones. 

One  should  also  examine  the  patient  further  to  ascertain  whether 
scars  or  neuromata  at  other  portions  of  the  body  than  the  head  could  be 
the  starting-point  of  the  convulsions,  since  it  is  well  known  that  such 
scars  or  neuromata  on  the  trunk  and  limbs  may  act  as  irritants  suffi- 
cient to  produce  epileptiform  convulsions. 

The  history  and  objective  examination  are  furtiicr  of  value  in  cases 
where  an  operation  has  been  performed  on  the  skull  or  brain,  for  the 
removal  of  tumors,  drainage  of  abscesses,  etc. 

Traumatic  epilepsy  generally  begins  in  one  group  of  muscles,  and 
extends  to  adjacent  areas  of  the  cortex,  in  a  definite  order.  Which 
centers  are  first  affected  depends  entirely,  in  the  case  of  bone,  dural,  or 
cortical  changes,  upon  the  situation  of  such  lesions.  The  onset  of  the 
convulsions  may  be  preceded  by  an  aura  which  consists  of  pain  in  the 
scar  or  of  numbness  in  the  affected  muscles. 

In  a  typical  case  of  traumatic  epilepsy  the  convulsions  are  Jacksonian 
in  character.  They  are  at  first  clonic,  and  then  tonic,  in  character, 
followed  by  more  or  less  stupor  and  coma,  and  by  temporary  paralysis 
in  the  affected  muscles.  Rarely  do  the  convulsions  tra\el  to  the  opposite 
side  of  the  body,  although  there  are  cases  in  which  the  convulsions 
are  general  from  the  very  beginning  of  the  disease. 

In  the  difl'erential  diagnosis  one  must  exclude  cortical  irritation,  due 
to  tumor  or  abscess  of  the  brain.  One  must  also  exclude  the  epilepti- 
form seizures  following,  infantile  or  adult  hemiplegia.     Again,   there 


64  SURGICAL    AFFECTIONS    OF    THE    HEAD. 

is  a  so-called  form  of  non-traumatic  Jacksonian  epilepsy  which  can  be 
readily  differentiated  by  the  absence  of  the  history  of  trauma  or  of  any 
objective  evidences  of  the  same.  In  the  common  or  essential  non- 
traumatic epilepsy  in  which  generahzed  convulsions  occur,  the  onset  of 
the  convulsions  is  usually  preceded  by  an  aura  and  there  is  no  histor}'- 
of  trauma.     This  latter  condition  has  also  usually  existed  from  infancy. 


MENTAL  CONDITIONS  FOLLOWING  CRANIAL  INJURY. 

The  diagnosis  of  whether  a  disturbed  mental  condition  is  a  direct 
sequence  of  an  injury  is  difhcult  to  say,  for  the  reason  that  in  many  cases 
the  symptoms  may  not  appear  until  months  or  years  after  the  injury, 
which  may  have  been  a  slight  one.  In  general,  one  may  speak  of 
primar}^  conditions  which  directly  follow  the  injury,  and  of  secondary  or 
late  sequels.  The  primary  conditions  most  frequently  found  are,  first, 
defective  memory,  and,  second,  recurrent  headache.  In  regard  to  the 
former,  it  may  disappear,  or  remain  as  a  permanent  condition.  There 
is  often  a  marked  loss  of  memory,  or  the  patient  only  forgets  the  common 
things  of  ever}'day  hfe.  Not  infrequently  the  musical  and  arithmetical 
faculties  are  lost,  and  there  is  a  lack  of  concentration  of  the  mind. 

The  third  symptom  of  psychical  change  is  greater  irritabihty. 
Vertigo  is  often  quite  marked,  especially  on  bending  forward.  Not 
infrequently  other  mental  symptoms  may  follow  the  injur}^,  especially 
if  there  has  been  contusion  of  the  frontal  lobes.  These  are  delirium, 
restlessness,  hallucinations,  and  insomnia.  These  latter  symptoms  dis- 
appear within  two  or  three  weeks  after  the  injur}^,  but  leave  a  state  of 
greater  mental  irritabihty,  so  that  the  patient  is  not  able  to  resume  his 
ordinary  occupation  for  some  time. 

The  late  traumatic  mental  changes  may  be  divided,  according  to 
Krafft-Ebing,  into  three  groups.  In  the  first  the  patients  gradually 
become  feeble-minded  and  idiotic,  and  associated  with  this  condition 
there  are  disturbances  in  coordination  and  paralysis.  In  a  second 
group  the  psychical  disturbance  develops  after  a  long  prodromal  stage, 
in  which  mental  irritabihty  and  change  of  character  of  the  patient  are 
noticed.  These  are  followed  by  maniacal  conditions,  or  by  progressive 
paralysis.  In  a  third  group,  the  trauma  seems  to  ha^•e  only  an  indirect 
influence,  affording  a  certain  predisposition  to  the  mental  disease, 
which  develops  as  the  result  of  other  accompanying  causes. 


DISEASES   OF   THE   SCALP. 


65 


Diseases  of  the  Scalp,  Skull,  and  Brain, 
diseases  of  the  scalp. 

Infection. 
The  most  frequent  variety  of  infection  of  the  scalp  is  in  the  form  of 
furuncles  and   carbuncles.     These  are  usually  situated  in  the  thick 
cellular  tissue  at  the  back  of  the  neck.     The  diagnosis  can  be  readily 


Fig.  27. — Lymph-nodes  of  Face  and  Neck. 
The  deep  nodes  are  shown  as  black  solid  areas;  the  superficial  as  a  black  circle:  P,  Lymph-nodes  lying 
within  capsule  of  parotid  gland;  those  lying  upon  the  parotid  and  beneath  the  skin  (preauricular  nodes)  are 
shown  as  black  circles;  C,  lymph-nodes  occasionally  present  in  substance  of  cheek;  5,  submaxillary  nodes 
lying  within  capsule  of  gland — those  lying  between  the  capsule  and  skin  are  shown  as  black  circles;  .1/,  sub- 
mental nodes;  O,  occipital  nodes;  R,  postauricular  or  mastoid  nodes;  D,  deep  cervical  nodes  lying  along  the 
anterior  and  posterior  borders  of  the  sternocleidomastoid  muscle  and  internal  jugular  vein,  communicating 
with  the  nodes  of  the  posterior  triangle. 


made  from  the  central  sujjpurating  point  in  a  furuncle  and  the  tense 
area  of  infiltration  surrounding  it,  which  is  ciuite  characteristic  of  cuta- 
neous infection  in  this  region.  In  a  carbuncle  the  area  of  induration  is 
much  more  extensive  and  there  are  multiple  foci  of  suppuration. 

5 


66  SURGICAL    AFFECTIOXS    OF    THE    HEAD. 

Carbuncles  may  become  so  large  that  practically  the  entire  space 
below  the  occipital  protuberance,  as  far  do^^^l  as  the  vertebra  prominens, 
is  occupied  by  a  suppurating  focus. 

Infection  of  the  Lymph-nodes. — ^The  lymph-nodes  draining  the 
scalp  are  situated  principally  in  front  of  and  behind  the  ear,  the  former 
lying  directly  upon  the  parotid  gland,  the  latter  lying  just  below  the 
superior  cuiTed  hne  of  the  occipital  bone.  These  may  become  enlarged, 
so  that  the  surgeon  is  at  times  consulted.  They  may  even  suppurate, 
the  suppuration  often  being  ver\'  obstinate  to  treatment.  The  diagnosis 
can  be  readily  made,  by  feehng  nodules  beneath  the  skin  situated  at  the 
characteristic  locations  (Fig.  27),  but  every  effort  should  be  made  to 
ascertain  where  the  primary  source  is.  At  times  pediculi  capitis, 
eczema,  and  furuncles  of  the  scalp  mil  cause  such  an  enlargement  and 
suppuration  of  the  lymph-nodes  draining  the  scalp. 

Phlegmon  of  the  Scalp, — This  usually  follows  infected  scalp 
wounds.  It  can  be  recognized  by  the  angr}-,  swollen  appearance  and 
the  tenderness  of  the  edges  of  the  wound.  The  granulations  become 
edematous  and  there  is  constant  discharge  of  pus.  Pus  may  accumu- 
late beneath  the  subaponeurotic  layer,  so  that  the  entire  scalp  is  raised, 
giving  rise  to  distinct  fluctuation  all  over  the  skull.  The  limits  of  the 
boggy  swelhng  are  the  superior  cun-ed  line  of  the  occipital  bone  behind, 
the  supraorbital  ridge  in  front,  and  the  zygomatic  processes  at  the  sides. 

There  is  always  danger  in  these  cases  of  a  septic  thrombosis  and 
meningitis,  and  the  symptoms  (see  page  59)  of  these  conditions  should 
be  looked  for,  especially  if  tlie  phlegmon  complicates  a  compound  skull 
fracture. 

Erysipelas  of  the  scalp  usually  exists  as  a  comphcation  of  the 
same  disease  in  the  face.  It  resembles  ordinan.'  infection  of  the  skin  of 
the  scalp  by  causing  a  tense  infiltration  whose  edge  is  sharply  marked. 
The  diagnosis  can  be  made  from  this  tense  infiltration  as  well  as  from 
the  many  small  bulte  or  bhsters  and  the  pinkish  discoloration  of  the 
skin  of  the  scalp,  which,  like  the  infiltration,  terminates  rather  sharply. 
Such  a  sharp  demarcation  is  characteristic  of  erysipelas  elsewhere,  and 
is  described  more  fully  in  the  diagnosis  of  facial  eiysipelas  on  page  91. 
There  is  usually  also  some  rise  of  temperature  and  moderate  constitu- 
tional disturbance. 

Tumors  of  the  Scalp. 
Tumors  of  the  scalp  may  be  either  benign  or  malignant.     The 
foiTner  are  far  more  frequent.     In  adult  Hfe  sebaceous  cysts  constitute 
the  larger  number  of  benign  tumors  of  the  scalp.     They  occur  either 


DISEASES    OF   THE    SCALP. 


67 


singly  or  as  multiple  tumors  and  can  be  recognized  from  the  fact  that 
the  tumor  projects  above  the  level  of  the  scalp,  the  skin  over  it  being 
stretched.  It  is  distinctly  movable  upon  the  aponeurosis,  and  as  a  rule 
the  skin  covering  it  is  not  adherent.  It  is  round  in  form  but  in  the 
occipital  region  may  be  polypoid.  If  the  surface  is  ulcerated  and  hard, 
carcinomatous  degeneration  has  occurred  (see  below). 

Dermoid  cysts  are  usually  smaller  than  sebaceous  cysts  and  are 
situated  at  definite  places,  such  as  the  root  of  the  nose,  inner  and  outer 
angles  of  the  orbit,  and  at  times  within  the  orbit  itself.  Their  size  varies 
from  a  hazekiut  to  an  egg.  Their  base  is  usually  fixed,  so  they  can  be 
moved  but  Httle  upon  the 
skull,  to  which  they  are  firmly 
attached. 

A  dermoid  cyst  must  be  dif- 
ferentiated from  a  meningo- 
cele. The  latter  occurs  in  the 
median  line  at  the  front  and  at 
the  back  of  the  skull  (Fig.  29). 
It  can  usually  be  compressed, 
pulsates,  and  enlarges  when 
any  exertion  is  made.  In 
children,  in  whom  meningo- 
celes are  most  frequently 
found,  crying  causes  them  to 
become  more  tense,  and  the 
reduction  of  the  contents 
causes  cerebral  pressure  symp- 
toms. After  a  meningocele 
has  been  reduced,  one  can 
often   feel  fhe   edges    of  the 

gap  in  the  skull  through  which  the  tumor  has  protruded  ('see  page 
71).    -         ■  . 

Among  the  rarer  forms  of  tumor  of  the  scalp  may  be  mentioned  a 
pneumatocele,  which  will  be  readily  recognized  by  the  fact  that  it  is  situated 
over  the  mastoid  or  frontal  regions,  usually  the  former.  It  contains  air, 
so  that  it  is  tympanitic  on  percussion.  It  is  soft  and  elastic,  and  the  air 
can  be  gradually  pushed  in  through  the  gap  in  the  skull. 

Lipoma  of  the  scalp  occurs,  chiefly  in  the  frontal  and  temporal 
regions,  as  a  flat,  soft  tumor,  which  does  not  raise  the  scalp  as  much  as 
either  dermoids  or  sebaceous  cysts.  In  the  temporal  region  it  may 
attain  some  size,  and  give  rise  to  a  sense  of  pseudo-fluctuation. 


Fig.  28. — Sebaceous  Cyst  of  Occipital  Region,  with 
Ulceration  of  Surface. 


68 


SURGICAL    AFFECTIONS    OF   THE    HEAD. 


Fibromata  are  rare.  They  are  usually  quite  soft,  and  often  present 
as  a  part  of  a  generalized  condition. 

Warts  can  be  readily  recognized  on  the  scalp.  They  are  quite 
small,  and  bleed  easily. 

Pigmented  moles  occur  quite  frequently  and  are  recognized  by 
their  brownish  color,  and  the  fact  that  they  are  sKghtly  raised  above 
the  level  of  the  skin  of  the  surrounding  scalp.  They  may  develop  into 
melanotic  sarcomata  (see  below). 

Vascular  tumors  of  the  scalp  are  most  often  present  in  the  form 
of  simple  angiomata  upon  the  forehead.  They  appear  as  bright  red 
spots,  slightly  raised  above  the  level  of  the  scalp.     The  color  can  be 


Fig.  29. — Location  of  Various  Tumors  of  Skull  and  Face  (Diagrammatic). 
D,  Location  of  dermoid  cyst  at  outer  angles  of  orbits;  DM,  location  of  dermoid  cysts  at  root  of  nose,  and 
of  meningocele  of  the  naso-frontal  type;   FM ,  naso-frontal  form  of  meningocele;   OM ,  occipital  form  of 
meningocele. 


made  to  disappear  by  pressure,  but  immediately  returns  when  the  finger 
is  taken  off. 

A  second  type  of  angioma  is  the  cavernous,  which  may  occur  with 
the  simple  or  capillary  form  or  be  present  independently.  If  the  latter 
is  the  case  the  scalp  is  only  shghtly  discolored,  of  a  purplish  hue,  and  the 
soft  tumor  can  be  caused  to  disappear  to  a  great  extent  by  pressure. 

The  fact  that  they  do  not  pulsate  and  that  there  is  no  gap  in  the 
skull  after  they  have  been  decreased  in  size  by  pressure,  readily  distin- 
guishes simple  and  cavernous  angiomata  from  meningoceles.  At  times 
they  increase  somewhat  in  size  when  the  child  cries,  which  may  lead 
one  to  suspect  it  to  be  a  meningocele. 

A  third  variety  of  vascular  tumor  is  the  cirsoid  aneurysm,  which 
can    be    recognized    as    a    mass    of    tortuous,  elongated,  and    dilated 


DISEASES   OF   THE   SCALP.  69 

arteries.  It  feels  like  a  bunch  of  worms  and  occurs  especially  in  the 
frontal  and  temporal  regions.  It  can  be  emptied  by  pressure,  but 
refills.  It  pulsates,  but  ceases  to  do  so  when  the  temporal  artery  is 
compressed.  This  pulsation  must  be  differentiated  from  that  of  a 
pulsating  soft  sarcoma,  by  the  peculiar  feeling  one  gets  of  elastic  tubes 
filled  with  blood. 

A  fourth  variety  of  vascular  tumor  is  the  traumatic  aneurysm,  in 
which  there  is  a  pulsating  tumor,  usually  in  the  temporal  or  frontal 
regions,  with  an  expansile  pulsation  and  a  distinct  bruit. 

A  fifth  variety  is  the  arterio-venous  aneurysm,  which  occurs  either  in 
the  temporal  or  posterior  auricular  arteries.  It  can  be  recognized  by 
the  marked  dilatation  of  the  superficial  veins  leading  to  it,  and  the 
peculiar  whirring  sound  at  the  point  of  communication  of  the  vein  and 
arter}'. 

Malignant  Tumors  of  the  Scalp. — Sarcomata  occur  either  as  mel- 
anotic sarcomata,  or  as  bleeding  warts,  in  elderly  people.  They  are 
usually  soft,  with  overhanging  edges,  and  can  be  recognized  as  belonging 
to  the  class  of  malignant  tumors  by  their  steady  growth  in  all  directions. 

Carcinoma  occurs  as  a  primary  form,  either  arising  from  the  seba- 
ceous cysts,  or  as  a  rodent  ulcer  on  the  forehead.  The  former  can  be 
recognized  by  the  ulceration  of  a  sebaceous  cyst,  and  the  marked 
induration  of  the  edges  of  the  ulcer. 

Inflammatory  Affections.    Diseases  of  the  Skull. 

Tuberculosis  of  the  skull  may  occur  at  any  age,  but  is  especially 
frequent  in  infancy  and  childhood,  in  the  mastoid  and  petrous  portions 
of  the  temporal  bone.  It  may  also  occur  in  the  frontal  and  parietal 
bones,  especially  when  there  are  tubercular  foci  elsewhere.  It  can  be 
recognized  by  its  slow,  insidious  character.  Unless  there  are  intracranial 
complications,  it  causes  but  little  tenderness  or  pain.  Cases  may  pre- 
sent themselves  with  one  of  two  conditions  present,  (a)  either  a  sinus, 
lined  with  typical  yellowish  tubercular  granulations,  leading  to  bare 
and  soft  bone,  or  (h)  as  an  unopened,  cold  abscess.  Under  the  latter 
conditions  care  should  be  taken  to  differentiate  such  an  abscess  in  the 
temporal  region  from  a  hpoma  (see  page  67). 

The  disease  is  a  very  progressive  one,  causing  steady  rarefaction  of 
the  bone,  and  often  forming  extradural  collections  of  pus.  These  can 
be  recognized  by  the  presence  of  a  dull  headache  and  tenderness,  and, 
in  case  of  a  large  collection  of  pus,  by  the  general  symptoms  of  intra- 
cranial pressure. 

Syphilis  of  the  Skull. — ^This  occurs  in  one  of  the  four  following 


70 


SURGICAL   AFFECTIONS    OF   THE    HEAD. 


0^" 


forms,  which  can  be  readily  diagnosed  by  a  careful  history,  a  search 
for  evidences  of  syphihs  elsewhere,  and  the  characteristic  local  findings : 
First,  as  a  periostitis,  in  the  early  weeks  of  the  secondary  stage. 
Here  it  produces  a  soft,  flat  elevation  of  the  periosteum,  which  is  extremely 
sensitive  and  causes  much  pain,  the  latter  being  especially  severe  at 
night. 

Second,  in  the  form  of  open  gummata  resulting  in  a  worm-eaten 
condition  of  the  bone  (Fig.  30).  Large  areas  of  both  tables,  but 
especially  the  outer,  become  necrotic,  and  form  sequestras  by  a  process 
of  progressive  osteoporosis  or  rarefaction.     Each  area  is  surrounded 

by  a  zone  of  osteosclerosis  or 
hardened  bone.  Perforation 
of  the  skull,  with  subdural 
collections  of  pus,  causing 
pressure  symptoms,  as  is  the 
case  in  tuberculosis,  is  quite 
rare  in  syphilis. 

The  third  is  in  the  form 
of  an  exostosis  and  enostosis 
of  the  skull.  It  is  usually  a 
result  of  osseous  gummata. 

Fourth,  hereditary  syphihs 
of  the  skull,  which  occurs  in 
the  form  of  ulcerations  on  the 
frontal  and  parietal  bones  of 
children,  and  the  formation  of 
nodules  over  the  parietal  emi- 
nences, known  as  Parrot's 
nodes. 

Acute  osteomyelitis  and 
periostitis  occur  after  septic  compound  fractures,  furuncles,  and  middle 
ear  disease.  Usually  there  is  considerable  pain  around  the  scalp  wound, 
the  scalp  itself  is  red  and  swollen,  there  is  distinct  fluctuation,  and  when 
the  wound  in  the  skull  is  examined  one  either  finds  sequestras,  or  the  diploe 
is  infiltrated  with  pus. 

The  chief  point  of  interest  in  the  diagnosis  is  to  be  able  to  exclude 
the  various  intracranial  complications  referred  to  on  page  56. 

Craniotabes. — ^This  disease  of  the  skull  accompanies  rickets,  and 
consists  of  a  softening  of  the  skull-bones,  especially  in  the  parietal  and 
occipital  regions,  so  that  the  skull  becomes  almost  translucent;  It  can 
be  readily  recognized  by  external  palpation,  the  skull  having  a  pecuhar 


Fig.  30. — Tertiary  Syphilitic  Necrosis  of  the  Fron- 
tal Bones. 
Note  the  sharp,    clean-cut   edges  of   the  area,   and  the 
necrotic  bone  in  the  center  of  the  ulceration. 


DISEASES   OF  THE   SCALP. 


71 


elastic  feeling,  so  that  the 
bone  can  be  distinctly  pressed 
inward  and  springs  back 
again. 

It  may  be  distinguished 
from  hydrocephalus,  which 
also  causes  a  thinning  of  the 
skull-bones,  by  the  fact  that 
the  head  never  attains  as  large 
a  size.  If  tonic  and  clonic 
convulsions  are  present  in  a 
rachitic  child,  such  a  cranio- 
tabes  may  be  mistaken  for  an 
abscess.  The  diagnosis  can 
be  made  by  consideration  of 
the  absence  of  the  causes  of 
suppuration. 


Congenital  Defects  of  the 
Skull. 

Meningocele  and  Hy- 
drocephalocele. — ^These  are 
found  chiefly  in  the  occipital 
region  and  at  the  root  of  the 
nose.  Rarely  do  they  project 
into  the  pharynx.  They  cause 
either  sessile  or  pedunculated 
tumors,  which  push  the  scalp 
before  them,  pulsate,  and  be- 
come tense  during  expiratory 
efforts.  Those  containing 
brain  substance  are  usually 
much  larger  than  those  con- 
taining simple  meninges. 
They  affect  the  brain  more 
than  the  latter.  Many  of  the 
meningoceles  can  be  reduced, 
but  cause  dullness.  If  the 
contents  can  be  reduced,  one 
can  palpate  a  bony  defect  in 
the  skull. 


Fig.  31. — Anterior  View  os  Case  of  Angioosteoma 
OF  THE  Left  Frontal  and  Parietal  Bones. 


Fig.  32. — Posterior  View  of  Angioosteoma  of  Parie- 
tal Bone. 
Same  case  as  shown  in  Fig.  31. 


72 


SURGICAL    AFFECTIONS    OF    THE    HEAD. 


Tumors  of  the  Skull. 
Osteomata. — ^This  form  of  tumor  may  occur  either  on  the  vault 
of  the  skull  or  in  one  of  the  accessory  sinuses,  such  as  the  frontal  and 
sphenoidal.  On  the  vault  of  the  skull  they  may  be  diagnosed  from  the 
fact  that  their  growth  is  very  slow,  their  borders  are  sharp,  they  are 
extremely  hard,  are  conical  or  mushroom  in  shape,  and  occur  usually 
in  the  parietal  and  frontal  bones.  The  osteomata  may  contain  large 
vascular  spaces  and  show  a  feeble  pulsation.     To  this  variety  the  name 

of  angioosteoma  has  been  given 
(Figs.  31  and  32). 

Osteomata  of  the  frontal 
sinus  cause  a  diffuse  swelling 
in  the  inner  angle  of  the  orbit, 
if  they  are  unilateral,  or  at  the 
middle  of  the  forehead,  if  bi- 
lateral. They  displace  the  eye- 
ball, and  can  only  be  recog- 
nized when  they  have  grown 
beyond  the  walls  of  the  frontal 
sinus.  The  diagnosis  can  be 
confirmed  by  the  use  of  the 

X-TSLJ. 

Osteomata  of  the  sphe- 
noidal sinus  can  be  recognized 
from  the  pressure  symptoms 
which  they  cause  on  the  eye- 
ball and  optic  nen-e.  If  oste- 
omata grow  toward  the  inner 
side  of  the  skull,  their  pres- 
ence can  be  only  suspected  from  the  focal  symptoms. 

Echinococcus  of  the  skull  usually  appears  in  the  bone  itself,  but 
as  often  between  the  dura  and  the  bone.  It  appears  upon  the  surface 
as  a  cystic  tumor,  which  can  be  recognized  as  an  echinococcus  if  the 
disease  is  found  elsewhere,  or  the  characteristic  booklets  are  found  in 
the  cystic  fluid. 

Sarcoma.— Sarcoma  of  the  skull  may  occur  as  a  primary  tumor 
in  the  periosteum  or  in  the  bone  itself.  Both  of  these  form  tumors 
which  are  hemispherical,  and  grow  rapidly,  are  hard  at  first,  and  later 
become  soft  and  ulcerated.  Rarely  an  osteosarcoma  occurs,  containing 
hard  and  bony  areas  (Fig.  33). 


Fig.  33. — Multiple  Osteo-sarcomata  of  the  Skull. 
The  white  arrows  point  to  tumors  situated  in  the  right 
parietal  and  left  frontal  bones  respectively.  The  protru- 
sion of  the  left  eye  is  caused  by  a  tumor  which  has  formed 
in  the  left  frontal  sinus,  pushing  the  eye  downward  and 
outward. 


NON-TRAUMATIC  SURGICAL  DISEASES  OF  BRAIN  AND  ENVELOPES.       73 

Secondary  sarcomata  are  more  often  multiple  than  the  primary. 
They  can  be  recognized  by  the  fact  that  they  have  all  of  the  charac- 
teristics of  the  primary  growth  just  referred  to,  and  the  history  or  pres- 
ence of  such  a  primary  focus. 

Primary  tumors  of  the  dura  or  of  the  frontal,  ethmoidal,  or  sphe- 
noidal sinuses  may  penetrate  the  skull  and  grow  externally  as  well  as 
into  the  cranial  cavity  itself  (Figs.  34  and  35).  They  cannot  be  dis- 
tinguished from  primary  skull  tumors,  unless  the  case  has  been  under 


Fig.  34.— Side  View  of  Sarcoma  of  Frontal  Bone 
Which  Invaded  Interior  of  Skull  and 
Orbit,  Causing  Displacement  Outward  of 
THE  Eye. 


Fig.  35. — Anterior  View  of  Tumor 
(Sarcoma)  Originating  in  Frontal  . 
Bone,  Which  Invaded  Cranium 
AND  Orbit  and  Caused  Displace- 
ment of  Eye.  Same  Case  Shown 
IN  Fig.  34. 


observation  'from  the  earliest  period.     These  dural  sarcomata  usually 
pulsate  and  cause  intracranial  symptoms. 

Primary  sarcomata  of  the  brain  may  grow  through  the  skull  and 
present  externally.  Their  growth  is  usually  more  diffuse  than  primary 
tumors  of  the  dura. 


NON-TRAUMATIC  SURGICAL  DISEASES  OF  THE  BRAIN  AND  ITS 

ENVELOPES. 

Hydrocephalus. 

The  chief  form  of  hydrocephalus  which  is  of  surgical  interest  is  the 

chronic.     It  may  be  congenital  or  acquired.     At  times  it  may  be  impos- 


74 


SURGICAL  AFFECTIONS  OF  THE  HEAD. 


Fig.  36. — Side  View  of  Child   Suffering  from  Hy- 
drocephalus. 
Note  how  the  face  seems  to  be  a  mere  parasite  upon  the 
enormous  enlargement  of  the  skull. 


sible  to  differentiate  in  a  given  case  whether  the  condition  was  a  con- 
genital one  or  not.  The  causes 
for  both  are  the  same  before 
the  sutures  and  fontanelles  are 
closed.  These  are  a  tubercular 
or  posterior  basic  meningitis, 
a  spina  bifida,  and  rachitis. 

The  diagnosis  of  hydro- 
cephalus should  never  be  made 
without  comparing  the  circum- 
ference of  the  head  with  that 
of  a  normal  child  at  the  same 
age. 

Hydrocephalus  must  be 
dift'erentiated  from  rickets,  and 
this  is  at  times  difficult,  because 
the  latter  disease  is  often  as- 
sociated with  hydrocephalus. 
They  can,  however,  be  dis- 
tinguished from  each  other  by 
the  fact  that  in  hydrocephalus  there  is  apt  to  occur  spastic  rigidity, 
accompanied  by  convulsions 
and  paralysis,  as  well  as  con- 
tractures in  the  paralyzed  parts 

(Fig-  37)-  _ 

There  is  great  impairment 
of  mental  development  in  hy- 
drocephalus. The  head  is  often 
retracted,  there  are  night  cries, 
unsteady  gait  and  emaciation. 
In  rickets  the  head  is  square  or 
box-shaped;  the  fontanelles, 
although  they  are  open,  do  not 
bulge;  there  is  usually  accom- 
panying craniotabes  but  the 
enlargement  is  not  so  marked 
as  in  hydrocephalus.  There 
are  also  usually  present  the 
characteristic  rachitic  enlarge- 
ments at  the  junction   of  the 

costal  cartilages  and  ribs  and  at  the  ends  of  the  long  bones,  especially 
at  the  lower  end  of  the  radius  and  ulna. 


Fig. 


StcoxDARY  Cu.\ii-.'.Lii„'.\i  ui  HIE  Wrist- .\nd 

FiXGER-JOINTS  IN  HYDROCEPHALUS. 


NON-TRAUMATIC  SURGICAL  DISEASES  OF  BRAIN  AND  ENVELOPES.       75 

Hydrocephalus  must  also  be  differentiated  from  tumors  arising  in 
early  life  from  the  third  ventricle  and  posterior  fossa  of  the  skull.  In 
these  the  enlargement  of  the  head  is  very  gradual  and  has  not  been 
present  from  birth,  as  in  congenital  hydrocephalus.  In  addition 
there  are  usually  other  general  and  focal  symptoms,  including,  in  the 
case  of  tumors,  the  presence  of  choked  disc. 

Tumors  of  the  Brain. 
The  diagnosis  of  tumors  of  the  brain  can  be  made  by  the  careful 
study  of  certain  general  and  focal  sjmiptoms.  The  general  sjmiptoms  in- 
dicate an  increase  of  intracranial  pressure.  The  focal  symptoms  are  the 
evidences  of  pressure  upon  locahzed  areas  of  the  brain,  causing  more 
or  less  interference  with  their  special  functions.  The  general  symp- 
toms in  the  order  of  their  frequency  are : 

I.  Headache. — ^The  headache  is  of  a  deep  boring  character,  usually 
quite  severe.  It  may  be  locahzed  over  the  seat  of  the  tumor  or  be 
diffuse  all  over  the  head.  In  tumors  of  the  posterior  fossa  (pons, 
medulla,  and  cerebellum),  the  pain  is  characteristically  situated  in  the 
occipital  region. 

II.  Vomiting.^The  character  of  cerebral  vomiting  is  that  it  occurs 
without  any  effort,  the  contents  of  the  stomach  being  thrown  at  times 
some  distance  in  a  projectile  manner.  The  vomiting  is  also  seldom 
preceded  by  nausea  and  is  independent  of  the  taking  of  food. 

III.  Optic  Neuritis. — ^This  is  present  at  some  stage  in  the  majority 
of  cases  in  one  or  both  eyes.  It  is  usually  of  such  a  degree  as  to  give 
rise  to  the  name  choked  disc.  The  larger  the  tumor,  the  more  marked 
is  this  SATnptom.  In  cerebellar  tumors  it  appears  quite  early,  while  in 
those  in  the  motor  region  it  appears  quite  late,  and  in  only  40  per  cent. 
of  the  cases.     It  ahnost  always  results  in  optic  atrophy. 

IV.  Mental  Symptoms. — Stupor  often  marks  the  onset  of  the  symp- 
toms. It  gradually  develops  into  coma,  which  varies  greatly  in  its 
intensity.  Remission  of  the  coma  aids  in  distinguishing  tumor  from 
abscess  of  the  brain,  because  the  stupor  and  coma  in  the  case  of  a  tumor 
increase  and  decrease  from  time  to  time  as  intracranial  pressure  rises 
or  falls.  The  psychical  symptoms  var\'  greatly  and  are  most  marked 
in  tumors  of  the  frontal  lobe.  There  may  be  simple  mental  failure 
(loss  of  memoiyj  and  dullness,  or  marked  mental  confusion,  or  e^•en 
actual  deHrium.  Witzelsucht  or  loquaciousness,  with  a  tendency  to 
joke  on  all  subjects,  is  occasionally  found  in  tumors  of  the  first  frontal 
convolution. 

V.  Sloiv  Pulse  and  Marked  Increase  0}  Blood- pressure. — In  many 


76  SURGICAL  AFFECTIONS  OF  THE  HEAD. 

cases  of  brain  tumor  both  of  these  symptoms  are  quite  marked,  the 
pulse  sinking  at  times  to  forty  beats  per  minute  and  the  blood-pressure 
rising  greatly,  as  determined  by  the  use  of  the  modified  Riva-Rocci 
apparatus. 

VI.  Vertigo. — ^This  is  especially  marked  in  cerebellar  tumors,  and 
is  of  value  as  a  symptom  if  other  causes  of  vertigo,  such  as  ear  and 
gastric  causes,  can  be  ehminated. 

VII.  Apoplectiform  attacks  occur  from  time  to  time  through  hem- 
orrhages into  the  tumors,  and  may  simulate  ordinary  apoplexy  in  the 
absence  of  a  complete  history. 

VIII.  General  convulsions  are  apt  to  occur  if  the  tumors  are  in  the 
cerebral  cortex. 

IX.  The  skull  is  tender  over  the  site  of  the  tumor  if  the  latter  is 
superficial. 

Focal  Symptoms. — Tumors  of  the  Frontal  Lobe. — ^There  are  no 
localizing  symptoms  unless  the  growth  compresses  the  motor  centers 
in  the  adjacent  pre-  and  postcentral  gyri,  or  compresses  the  motor 
speech- center  in  the  third  left  frontal  convolution.  Marked  disturbances 
in  mentality  are  usually  associated  with  general  symptoms  of  cerebral 
pressure  in  tumors  of  the  frontal  lobe,  and  are  more  marked  in  those  of 
the  right  side.  These  mental  disturbances  are  mental  dullness  or  con- 
fusion, witzelsucht,  irritabihty  and  childishness,  or  loss  of  memory  (Fig. 
20). 

Motor  Region. — ^Attacks  of  Jacksonian  epilepsy  occur,  often  pre- 
ceded by  disturbances  of  sensation  such  as  tinghng  in  the  affected 
parts,  in  tumors  of  the  motor  region,  and  in  irritation  of  the  motor  center 
from  any  cause.  The  parts  which  twitch,  or  are  affected  by  distur- 
bances of  sensation  and  motion,  vary  according  to  the  area  involved 
(Fig.  1 9) ,  so  that  it  is  possible  to  more  accurately  localize  tumors  of  this 
region  than  those  of  almost  any  other.  As  the  tumor  grows,  the  attacks 
extend  over  a  greater  number  of  muscles,  but  are  always  locaHzed, 
according  to  the  situation  of  the  motor  centers  in  the  cortex.  For 
example,  it  may  begin  in  the  muscles  of  the  leg  and  then  involve  those 
of  the  arm,  and  later  still  those  of  the  face,  on  the  side  of  the  body 
opposite  to  that  upon  which  the  tumor  is  situated  in  the  brain.  Later 
in  the  course  of  the  disease  pareses  or  paralyses  or  even  contractures 
occur  in  the  affected  muscles.  Other  symptoms  than  those  of  cortical 
irritation  or  pressure  upon  the  motor  centers  are  not  infrequently 
associated  in  tumors  of  the  motor  region,  some  through  direct  pressure 
upon  adjacent  areas  in  the  parietal  or  frontal  lobes,  others  due  to  indi- 
rect effects  of  pressure  (Femwirkung).     If  the  tumor  is  on  the  right  side 


NON-TRAUMATIC  SURGICAL  DISEASES  OF  BRAIN  AND  ENVELOPES.        77 

in  left-handed  people,  there  may  be  motor  aphasia  or  agraphia;  if  the 
third  frontal  convolution  is  compressed  there  is  a  loss  of  muscle  sense 
and  anesthesia  of  the  paralyzed  hmb  through  pressure  upon  the  parietal 
lobe. 

Tumors  of  the  Parietal  Lobe. — ^Tumors  of  this  lobe  can  be  recog- 
nized by  the  absence  of  attacks  of  Jacksonian  epilepsy  and  of  paralysis, 
and  by  the  presence  of  a  marked  loss  of  muscle  sense  or  astereocognosy. 
If  situated  in  the  lower  part  of  the  parietal  lobe,  they  may  produce 
alexia  and  often  agraphia.  Tumors  of  the  left  temporo-sphenoidal 
lobe  produce  word-deafness,  paraphasia  and  auditory  hallucinations. 
This  is  the  case  especially  in  tumors  of  the  first  left  temporo-sphenoidal 
gyrus.  In  tumors  of  the  posterior  portion  of  the  left  temporo-sphenoidal 
lobe,  and  extending  toward  the  occipital  lobe,  there  is  visual  aphasia. 

Tumors  of  the  Occipital  Lobe. — ^Tumors  involving  the  cuneus 
and  first  occipital  convolution  produce  homonymous  hemianopsia. 
Involvement  of  other  portions  of  the  lobe,  if  the  cuneus  is  not  greatly 
involved,  produces  soul-blindness,  or  incapacity  to  understand  the 
things  which  one  sees. 

Tumors  of  the  Cerebellum. — ^Tumors  of  the  cerebellum,  in  addi- 
tion to  producing  the  well-marked  symptoms  of  increased  intracranial 
pressure,  referred  to  under  the  head  of  general  symptoms,  produce 
somewhat  characteristic  focal  symptoms.  Vomiting  is  quite  frequent. 
Early  optic  neuritis  with  bhndness  occurs  verv^  early,  and  paralysis  of 
the  external  rectus  muscle  is  very  common  and  often  bilateral.  There 
is  also  apt  to  be  rigidity  of  the  neck,  and  involvement  of  the  oUsLCtory, 
oculomotor,  and  trigeminal  nerves  on  the  side  of  the  tumor.  One  of 
the  most  characteristic  symptoms  is  a  severe  occipital  headache,  most 
marked  upon  arising.  Attacks  of  amyasthenia  and  general  vertigo 
are  also  frequent.  Another  characteristic  symptom  is  the  so-called 
cerebellar  ataxia.  This  latter  is  especially  marked  in  children,  who 
have  a  tendency  to  fall  to  one  side  in  walking;  usually  toward  that  upon 
which  the  tumor  is  situated. 

Tumors  of  the  Pontomedullocerebellar  Space. — A  class  of 
tumors  has  been  recently  describe-d  whose  essential  features  distinguish 
them  from  tumors  of  the  cerebrum  and  cerebellum.  This  feature  is 
the  early  appearance  of  symptoms  referable  to  the  fifth  or  eighth  cranial 
nerves.  When  involving  the  eighth  nerv-e  they  are  sometimes  described 
under  the  name  of  neurofibromata  of  the  acoustic  nerve.  They  grow 
slowly,  hence  the  symptoms  referable  to  the  inN-olvement  of  the  fiftli  or 
eighth  nen-e  may  precede  the  other  symptoms  for  a  long  period.  In  the 
case  of  the  fifth  nerve  these  prodromal  symptoms  are  obstinate  and 


78  SURGICAL    AFFECTIONS    OF    THE    HEAD. 

show  themselves  as  atypical  attacks  of  facial  neuralgia,  for  which  no 
other  peripheral  or  central  cause  can  be  found.  The  symptoms  of  the 
early  involvement  of  the  eighth  nen^e  are  tinnitus  aurium  with  progres- 
sive diminution  of  hearing  and  aural  vertigo.  As  the  tumor  increases  in 
size,  we  have  other  evidences  of  pressure. 

The  diagnosis  rests  upon  the  symptom- complex  of  tumors  of  the 
posterior  fossa,  preceded  by  well-marked  and  long- continued  signs  of 
auditory  or  trigeminal  involvement.  These  general  and  focal  symptoms 
are  those  of  increased  intracranial  pressure  in  the  posterior  fossa  and 
are — (i)  general:  headache,  vertigo,  vomiting,  optic  neuritis,  brady- 
cardia; (2)  focal:  peduncular  ataxia,  cerebellar  ataxia,  lateropulsion, 
hemiasynergy,  homocontralateral  and  crossed  paralyses  of  the  extremi- 
ties, paralysis  of  the  cranial  nerves  at  the  base  of  the  skull  (especially 
the  fifth,  sixth,  and  seventh),  dysarthria,  dysphagia,  nystagmus,  paralysis 
of  the  conjoint  movements  of  the  eyes,  inequahty  of  the  pupils,  and 
attacks  of  Adams- Stokes  syndrome. 

Before  making  a  diagnosis  of  a  primary  tumor  of  these  nerves,  one 
must  exclude  primary  disease  of  the  base  of  the  skull  and  meninges, 
such  as  syphihs  and  tumors  of  the  bones  of  the  base  of  the  skull,  and 
also  exclude  aneurysm  of  the  vertebral  arteiy. 

Tumors  of  the  Middle  Fossa  of  the  Skull.— These  have  their 
origin  either  in  the  pituitary  body  or  the  optic  chiasm.  If  the  pituitary 
body  is  involved  the  symptoms  may  for  a  long  period  be  those  of  acro- 
megaly (Fig.  38)  and  the  general  symptoms  of  intracranial  pressure  may 
not  appear  for  a  long  period. 

In  tumors  involving  the  optic  chiasm  irregular  forms  of  hemianopsia 
appear.     Optic  neuritis  and  atrophy  is  a  very  early  symptom. 

The  diagnosis  of  whether  a  tumor  of  the  train  exists,  and  where 
it  is  located,  may  be  made  from  a  consideration  of  the  general  and  focal 
symptoms  just  referred  to.  Of  the  former,  the  most  constant  are  the 
headache,  the  vomiting,  the  choked  disc,  slow  pulse,  and  mental  symp- 
toms, including  stupor  or  coma,  as  the  case  may  be.  The  focal  will 
depend  upon  the  location  of  the  tumor  and  the  extent  to  which  neigh- 
boring areas  of  the  cerebrum  or  cerebellum  are  pressed  upon. 

In  regard  to  the  nature  of  the  tumor,  variations  in  pressure — that 
is,  remission  in  the  symptoms  and  apoplectic  attacks — speak  for  gHo- 
mata.  These  occur  especially  in  childhood  and  early  hfe.  SyphiHtic 
gummata  can  only  be  distinguished  from  other  tumors  of  the  brain  by 
the  history  of  preceding  infection,  or  finding  evidences  of  syphihs 
elsewhere  in  the  body.     They  are  apt  to  occur  late  in  hfe. 

Multiphcity  of  symptoms  speaks  for  tubercles.     These  occur  espe- 


NON-TRAUMATIC  SURGICAL  DISEASES  OF  BRAIN  AND  ENVELOPES.       79 

cially  in  childhood,  and  there  is  often  evidence  of  a  tuberculous  focus 
elsewhere. 

The  most  frequent  variety  of  tumor  of  the  brain  is  the  tubercle. 
The  next  most  frequent  is  sarcoma.  Carcinoma  and  parasitic  cysts 
(echinococcus  and  cysticercus)  are  comparatively  rare.  For  practical 
purposes  it  will  only  be  necessary,  as  regards  the  nature  of  the  tumor,  to 
distinguish  between  tubercle,  ghoma,  and  sarcoma.  The  two  former 
occur  most  frequently  in  childhood,  while  sarcomata  occur  in  aduk  hfe. 


Fig.  38. — Tumor  of  Pituitary  Body  Causing  Acromegaly. 


In  the  differential  diagnosis  of  tumor  of  the  brain  one  must  exclude 
abscess  of  the  brain.  Multiple  sclerosis  may  also  simulate  a  tumor, 
especially  if  there  is  optic  neuritis  or  atrophy  present,  but  there  are  usually 
no  stupor,  convulsions,  slow  pulse,  vomiting,  aphasia,  or  cortical  epi- 
lepsy present  in  this  disease. 

The  eye  should  be  examined  in  every  case  of  long-continued  head- 
ache, and,  if  choked  disc  be  found,  the  following  other  causes  for  it 
should  be  excluded:  Hydrocephalus,  meningitis,  abscess  of  the  brain, 
nephritis,  chlorosis,  and  chronic  lead-intoxication. 


8o  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

The  differential  diagnosis  of  abscess  from  tumor  of  the  brain  is 
given  in  the  following  table : 

Tumor.  Abscess. 

1.  No  primary  focus  of  infection  but  often         i.  Suppurating  area  in  ear,  nose,  pharynx^ 

history  of  syphilis  or  malignant  dis-  scalp,  or  lung  abscess, 

ease  of  other  organs. 

2.  Very  slow  development.  2.  More  rapid. 

3.  More   definite  focal  symptoms.  3.  Focal  symptoms  often  present  but  not 

so  definitely  localized  as  in  tumor. 

4.  No  rigors  or  septic  symptoms.  4.  Often  begins  with  chills,  septic  s}Tnp- 

toms  often  continue. 

5.  Temperature   normal   or   slightly   and         5.  Temperature   subnormal,    other   times 

irregularly  elevated.  higher — pus  temperature. 

6.  Pulse  slow.  6.  Not  slow  as  a  rule. 

7.  Constant  headache.  7.  Not  a  constant  or  prom.inent  symptom. 

8.  Projectile    vomiting    frequently  pres-         8.  Not  often;    vomiting,  if  present,  more 

sent.  frequent   and  not   projectile. 

9.  General    symptoms    of    pressure    pro-         g.  When     present,  they  vary    greatly    in 

gressive.  intensity. 

ID.  Choked  disc  constant.  to.  Not  constant. 


THE    INTRACRANIAL    COMPLICATIONS   OF   MIDDLE   EAR   AND   MAS- 
TOID SUPPURATION. 

These  are: 

1.  Epidural  abscess  or  otitic  pachymeningitis. 

2.  Purulent  leptomeningitis. 

3.  Serous  meningitis. 

4.  Cerebral  and  cerebellar  abscess. 

5.  Sinus  thrombosis. 

L  Extradural  Abscess. 
(Epidural  or  Perisinuous  Abscess.) 

This  condition  is  most  frequently  due  to  the  extension  of  infection 
from  a  diseased  mastoid  or  sigmoid  sinus.  It  is  more  frequent  on  the 
right  side.  It  is  usually  found  during  the  operation  for  mastoid  suppu- 
ration or  may  be  suspected  as  a  complication  if  symptoms  such  as  fever, 
headache,  tenderness,  edema  around  the  wound,  and  profuse  discharge 
of  pus  persist,  after  opening  the  mastoid. 

Focal  symptoms  are  rare  except  in  children.  If  the  extradural 
abscess  is  on  the  left  side  there  may  be  sensory  aphasia.  If  it  is  beneath 
the  dura  of  the  middle  fossa  there  may  be  pareses  of  the  opposite  half 
of  the  body  and  disturbances  of  sensibihty.  There  are  also  general 
symptoms  of  increased  intracranial  pressure  such  as  somnolence, 
vomiting,  slow  pulse,  pain,  and  choked  disc. 


PURULENT    LEPTOMENINGITIS. 


8i 


All  of  these  symptoms  may  be  present  in  purulent  meningitis  and 
cerebral  abscess,  so  that  the  diagnosis  must  be  made  to  a  great  extent 
from  the  local  findings,  which  are  as  follows: 

1.  Persistence  of  profuse  purulent  discharge  from  the  ear  after  a 
mastoid  operation. 

2.  Edema  and  tenderness  around  the  wound  and  the  foimation  of 
subperiosteal  and  subcutaneous  abscesses  and  fistulas  just  behind  the 
mastoid  or  on  the  squamous  portion  of  the  temporal  bone. 


II.  Purulent  Leptomeningitis. 

This  may  appear  in  an  acute  or  protracted  form.  As  in  other  foiTns 
of  intracranial  comphcation  of  middle  ear  suppuration,  there  are  both 
general  and  focal  brain 
symptoms  in  addition  to 
those  of  the  local  infec- 
tion. 

The  general  signs  of 
intracranial  pressure  are: 

(a)  Headache.  This 
may  be  on  the  side  of  the 
disease  alone.  It  may  be 
frontal  or  occipital  or  be 
present  over  the  entire 
head.  It  is  usually  quite 
severe. 

(b)  Optic  neuritis. 
This  may  or  not  be 
present.  It  is  less  fre- 
quent in  a  leptomeningitis 
than  in  cerebral  or  epi- 
dural abscess.     It  is  more 

often  found  in  basilar  than  in  cortical  leptomeningitis. 

(c)  The  pulse  is  rapid  and  there  is  often  stupor  and  dchrium. 

(d)  Respiration  is  slow,  irregular  at  times,  and  may  be  Cheyne- 
Stokes  in  character. 

The  focal  signs  depend  upon  whether  the  meningitis  is  most 
marked  at  the  base  or  on  the  convexity.  If  the  process  is  pre- 
dominant on  the  latter  there  may  be  focal  signs  such  as  one  expects 
to  find  only  in  a  cerebral  or  cerebellar  abscess.  These  are  paralyses 
upon  the  opposite  side  of  the  body,  convulsions,  motor  aphasia 
or    agraphia.     If  most   marked   at  the   base  there  is  rigidity  of  the 


Fig.  3g. — Modes  of  Transmission  of  Infection  from  Mas- 
toid Process. 
The  arrows  show  the  direction  in  which  infection  travels: 
(i)  into  temporo-sphenoidal  lobe,  TS;  (2)  into  cerebellum,  C; 
(3)  into  lateral  sinus,  SL,  and  free  apex  of  mastoid  into  tissues 
of  the  neck,  M . 


82  SURGICAL   AFFECTIONS   OF  THE  HEAD. 

neck  and  paralyses  of  the  cranial  nen'es  (especially  of  the  fourth  and 
sixth  nerv^es). 

In  the  acute  form  the  temperature  is  high,  while  in  the  protracted 
form  it  may  be  normal  or  subnormal. 

It  can  only  be  differentiated  from  an  extradural  abscess  by  the 
results  of  the  operative  treatment,  i.  e.,  if  the  condition  of  the  patient 
improves  after  opening  the  skull,  an  extradural  focus  existed.  If  there 
is  a  continuation  and  progression  of  the  symptoms,  leptomeningitis  is 
present. 

Only  by  finding  tubercles  in  the  choroid  coat  of  the  eye  or  tubercle 
baciUi  by  lumbar  puncture  can  one  positively  difl'erentiate  the  pro- 
tracted form  from  a  tubercular  meningitis.  Con\Talsions  are  less  com- 
mon, however,  in  simple  purulent  meningitis  than  in  tubercular. 

From  the  epidemic  form  of  cerebrospinal  meningitis,  one  can 
differentiate  it  by  the  more  marked  neck  rigidity  and  opisthotonos  and 
by  finding  the  meningococcus  by  lumbar  puncture. 

III.  Meningitis  Serosa  (Serous  Meningitis). 

This  may  also  occur  in  an  acute  or  chronic  form,  and  is  in  reaHty 
an  edema  of  the  meninges.  The  symptoms  are  similar  to  those  of  the 
purulent  variety  just  described  and  one  can  only  differentiate  it  by  the 
absence  of  fever,  by  the  absence  of  pus  in  the  lumbar  puncture,  and  the 
course  of  the  disease,  which  tends  to  recovery  in  the  majority  of  cases. 

The  symptoms  of  the  chronic  form  are  similar  to  those  of  tumor, 
both  the  general  and  focal  symptoms.  It  is  only  by  recalling  the 
fact  that  the  symptoms  have  appeared  after  a  middle  ear  disease  and  the 
tendency  to  spontaneous  recoveiy  that  one  can  make  a  diagnosis. 

IV".  Abscess  of  the  Brain. 
Indefinite  symptoms  such  as  sHght  headache  and  mental  depression 
and  evening  rise  of  temperature  may  exist  for  weeks  to  months  in  a 
patient  sufl'ering  from  a  chronic  otitis  media  and  then  suddenly  marked 
cerebral  symptoms  appear.  In  other  cases  the  symptoms  may  appear 
as  a  complication  of  one  of  the  three  following  conditions  : 

(a)  A  chronic  purulent  discharge  may  suddenly  cease. 

(b)  x\s  an  accompaniment  of  an  acute  otitis  media  and  mastoiditis. 

(c)  Acute  exacerbation  of  a  chronic  purulent  discharge. 

The  majority  of  the  abscesses  are  located  in  the  temporo-sphenoidal 
lobe,  the  remainder  in  the  cerebellum  fFig.  39). 
The  general  symptoms  of  brain  abscess  are: 
I.  Headache  which  may  be  located  over  any  portion  of  the  head, 


ABSCESS    OF    THE    BRAIN.  83 

SO  that  it  is  of  little  value  as  a  symptom  in  localizing  the  seat  of  the 
abscess. 

2.  Nausea  and  vomiting. 

3.  The  patient  is  mentally  dull  and  becomes  stuporous.  As  the 
intracerebral  compression  advances,  coma  sets  in. 

4.  Convulsions  occur,  which  are  either  locahzed  or  general.  They 
are  most  frequently  found  in  children. 

5.  Optic  neuritis  is  more  frequently  present  in  abscess  of  the  brain 
than  in  any  other  form  of  intracranial  suppuration.  It  is  usually 
simultaneous  in  its  appearance  in  both  eyes,  but  may  exist  on  the 
affected  side  some  time  before  appearing  in  the  other  eye.  It  is  not  as 
constant  a  symptom  as  in  the  case  of  a  cerebral  tumor  and  may  not 
appear  until  late  in  the  disease. 

6.  Slow  pulse.  This  if  present  is  a  valuable  sign  of  an  increased 
intracranial  tension,  but  it  is  quite  inconstant  in  its  appearance. 

7.  Locahzed  tenderness  of  the  skull  is  often  present  over  the  seat 
of  the  abscess. 

Focal  Symptoms  of  Brain  ^Abscess. — Temporo-sphenoidal  Ab- 
scesses. Irritation  and  Paralytic  Symptoms. — ^These  are  pareses  of  the 
face,  arm,  and  leg,  on  the  opposite  side  of  the  body,  often  accompanied 
by  spasms  or  convulsive  movements  in  the  affected  muscles.  Usually 
the  face  is  involved  first,  then  the  arm,  and  last  of  all  the  leg  centers. 

Cortical  facial  paralysis  can  be  distinguished  from  the  peripheral 
form  by  the  fact  that  in  the  former  the  eye  muscles  (orbicularis  palpebra- 
rum and  corrugator  supercihi)  supphed  by  the  facial  are  not  involved. 
Abscesses  of  this  lobe  may  also  cause  hemianesthesia  and  homonymous 
hemianopsia  through  indirect  pressure.  The  latter  two  symptoms  are 
often  absent.  In  addition  there  may  be  paralysis  of  the  motor  oculi 
nerve  on  the  side  of  the  abscess.  In  a  similar  manner  there  may  be 
hemianesthesia  or  motor  aphasia,  also  through  indirect  pressure. 

Abscess  of  the  Cerebellum. — ^An  abscess  situated  here  usually  causes 
vomiting  and  vertigo  quite  early.  There  are  all  kinds  of  pressure 
symptoms  on  the  medulla,  such  as  crossed  paralysis,  bilateral  paralysis, 
and  marked  slow  respiration  and  pulse. 

Diagnosis  of  Otitic  Cerebral  Abscesses  in  General. — ^The  diag- 
nosis of  an  otitic  cerebral  abscess  is  impossible  during  the  latent  stage, 
as  well  as  in  the  terminal  stage  when  the  symptoms  of  meningitis,  such 
as  vomiting,  restlessness,  clonic  spasms,  rapid  pulse  and  respiration  and 
high  temperature  appear.  If  during  this  terminal  stage  the  abscess 
has  ruptured  into  the  ventricle,  instead  of  through  the  meninges,  the 
pupils    become  widely  dilated,  the  respirations  and  temperature  are 


84  SURGICAL    AFFECTIONS    OF   THE   HEAD. 

very  high,  and  convulsions  and  tetanic  seizures  are  followed  by  coma 
and  death.  The  only  stage  in  which  a  diagnosis  can  be  made  is  in 
the  so-called  manifest  stage,  and  even  in  this  it  is  often  uncertain.  It 
is  especially  difficult  in  children,  because  the  localizing  signs  are  less 
marked  and  it  is  difficult  to  differentiate  a  tubercle  from  an  abscess. 
The  diagnosis  is  easy  if  one  finds  an  external  fistula  leading  to  the  abscess 
or  if  one  opens  the  mastoid  and  finds  a  fistula  leading  through  diseased 
bone  to  the  abscess.  In  the  majority  of  cases,  however,  there  is  no 
external  fistula  and  one  must  depend  on  the  brain  symptoms  alone. 

The  differential  diagnosis  between  an  extradural  and  an  intracere- 
bral or  cerebellar  abscess  is  very^  difficult  unless  found  at  operation, 
because  both  may  cause  the  same  symptoms,  especially  in  children. 
The  diagnosis  from  tumor  is  the  most  difficult  of  all,  especially  in 
children  with  tubercular  disease  elsewhere.  Here  the  multipHcity  of 
symptoms  through  the  presence  of  multiple  tubercles  speaks  for  tumor, 
whereas  symptoms  which  are  due  to  the  most  frequent  location  of 
cerebral  abscess  speak  for  the  latter. 

Optic  neuritis  is  usually  more  marked  in  tumors  than  in  abscesses, 
and  present  at  an  earher  stage.  The  symptoms  both  general  and 
focal  of  a  tumor  are  slower  in  making  their  appearance,  and  there  are 
apt  to  be  periods  of  temporar}-  improvement.     (See  page  80.) 

V.  Sinus  Thrombosis. 

The  majority  of  these  occur  as  a  comphcation  of  mastoiditis  or  after 
a  mastoid  operation  has  been  performed.  There  are  two  classes  of 
cases : 

1.  Those  with  marked  symptoms  of  sinus  thrombosis  and  pyemia. 

2.  Those  which  resemble  a  septicemia  in  type  and  have  no  local 
signs  of  sinus  involvement. 

The  symptoms  of  the  first  clinical  fomi  are: 

1.  Temperature.  The  fever  is  of  the  remittent  type,  there  being  a 
difference  of  4  to  5  degrees  in  the  daily  temperatures. 

2.  Chills  and  sweats  accompany  the  rises  in  temperature  but  may 
be  absent,  especially  in  children. 

3.  The  pulse  varies  according  to  the  temperature,  being  120  to  140, 
during  the  chills. 

4.  The  pain  in  the  head  is  usually  very  severe,  much  more  so  than 
in  an  ordinary  case  of  mastoiditis,  and  is  referred  to  the  side  of  the  head 
and  to  the  occipital  region. 

5.  The  sensorium  is  clear  unless  there  is  a  compHcating  abscess  or 
meningitis. 


OPTIC    SINUS    THROMBOSIS.  85 

6.  Optic  neuritis  and  choked  disc  are  present  only  in  cases  of  caver- 
nous sinus  thrombosis. 

7.  Nausea  and  vomiting  are  usually  present  to  a  greater  or  less  degree. 

8.  The  spleen  is  enlarged  and  there  are  evidences  of  metastases  in 
the  lungs,  subcutaneous  tissues,  and  joints.  The  embohc  abscesses  in 
the  lungs  can  be  recognized  by  pains,  coarse  rales  at  various  places,  and 
prune-juice  expectoration.  These  signs  at  first  are  localized  but  later 
are  present  over  both  lungs  and  may  result  in  empyema  or  in  pyopneu- 
mothorax. 

9.  Symptoms  of  thrombosis  of  the  individual  sinuses.  In  the  case 
of  the  sigmoid  sinus  these  are : 

(a)  The  internal  jugular  vein  is  occasionally  to  be  felt  as  a  firm  tender 
cord.     This  may  be  simulated  by  inflamed  glands. 

(b)  Signs  of  compression  of  the  ninth,  tenth,  eleventh,  and  twelfth 
cranial  nerves — such  as  dyspnea,  dysphagia,  hoarseness,  and  slow  pulse. 

(c)  Edema  of  the  mastoid  region. 

In  the  case  of  the  cavernous  sinus  they  are: 

(a)  Edema  of  the  forehead  and  eye-lids,  chemosis,  hyperemia  of  the 
retina,  and  optic  neuritis  (the  latter  is  fairly  constant  in  this  form  of 
thrombosis). 

(b)  Paralysis  of  the  third,  fourth,  and  sixth  nerves. 

(c)  Retrobulbar  edema  with  exophthalmos. 

(d)  Neuralgia  of  the  supraorbital  nerve  (deep-seated  pain). 

(e)  Dilated  supraorbital,  angular,  and  frontal  veins. 

The  above  ocular  symptoms  may  appear  in  one  or  both  eyes. 

10.  Leukocytosis  is  always  present. 

The  diagnosis  of  the  pyemic  form  of  sinus  thrombosis  may  be  made 
from  the  remittent  type  of  fever,  splenic  tumor,  metastases,  and  local 
signs  of  thrombosis  of  either  the  sigmoid  or  cavernous  sinuses.  If 
associated  -with  meningitis  or  abscess  the  symptoms  of  thrombosis 
predominate. 

The  septicemic  form  is  characterized  by  the  high  continuous  fever, 
rapid  weak  pulse,  septic  diarrhea,  icterus,  and  nephritis.  This  form 
can  be  distinguished  from  typhoid  by  the  absence  of  the  Widal  reaction 
and  the  presence  of  leukocytosis  as  well  as  by  the  local  signs  of  mastoid 
involvement. 


86  SURGICAL   AFFECTIONS   OF   THE   HEAD. 

Injuries  and  Diseases  of  the  Face. 

INJURIES  OF  the  SOFT  PARTS  OF  THE  FACE. 

The  principal  points  of  diagnostic  interest  in  regard  to  injuries  of 
the  soft  parts — that  is,  the  skin  and  subcutaneous  tissue — of  the  face, 
is  that  contused  wounds  around  the  orbit  show  a  relatively  larger 
amount  of  swelling  than  similar  wounds  in  other  parts  of  the  body, 
owing  to  the  loose  arrangement  of  the  subcutaneous  connective  tissue. 

In  contusions  of  the  skin  of  the  nose  there  is  but  httle  swelling  or 
discoloration.  It  not  infrequently  happens  that  blows  upon  the  nose, 
especially  over  the  root  of  the  nose,  are  followed  by  a  considerable 
discoloration  and  sweUing  of  the  skin  of  the  eyelids,  which  may  not 
appear  until  from  twenty-four  to  forty-eight  hours  after  the  injury. 
Contused  wounds  around  the  orbit  have  sharp  edges,  as  though  inflicted 
with  a  cutting  instrument. 

Incised,  lacerated,  and  gunshot  wounds  of  the  face  present  no  difh- 
culty  in  diagnosis,  and  resemble  in  almost  every  respect  similar  wounds 
elsewhere  in  the  body.  As  is  the  case  in  the  scalp,  a  large  flap  of  skin 
may  be  detached  and  still  be  followed  by  primary  union. 

In  wounds  penetrating  the  duct  of  Steno,  in  any  portion  of  its  course, 
a  salivary  fistula  is  apt  to  follow,  if  the  duct  is  cut.  This  occurs  most 
frequently  in  that  portion  of  the  duct  which  passes  through  the  buc- 
cinator muscle,  that  is,  about  opposite  the  second  molar  tooth. 

A  division  of  the  facial  muscles  causes  no  ill  effects,  with  the  excep- 
tion of  the  levator  palpebr^  muscle,  whose  injury  may  result  in  inabihty 
to  raise  the  upper  lid. 

Injuries  of  the  arteries  and  nerves  of  the  face  occur  in  connection 
with  lacerated  and  incised  wounds,  and  at  times  after  gunshot  wounds. 
Bleeding  from  the  facial  artery  or  its  larger  branches  is  usually  quite 
profuse.  Injury  of  the  facial  nerve  is  of  comparativly  Httle  significance, 
unless  the  main  trunk  of  the  nerve  is  injured  before  it  divides  within  the 
parotid  gland. 

There  is  great  danger  of  infection  of  the  antrum  in  punctured  wounds 
of  the  face.  In  gunshot  wounds  the  structures  injured  vary  according 
to  the  course  of  the  bullet,  the  chief  danger  being  a  laceration  of  the 
internal  maxillary  artery,  which  will  result  in  the  rapid  formation  of  a 
hematoma  and  the  escape  of  blood  into  the  mouth. 

Bums  and  freezing  affect  especially  the  tip  of  the  nose  and  the  more 
exposed  portions  of  the  cheek,  and  may  result  in  deeper  loss  of  tissue, 
with  resultant  cicatrization  and  deformities.  This  is  especially  true  of 
bums,  which  may  cause  marked  ectropion. 


INJURIES    OF   THE    BONES    OF   THE    FACE. 


87 


INJURIES  OF  THE  BONES  OF  THE  FACE. 
Fractures. 

Fractures  of  the  nasal  (Fig.  40)  bones  occur  usually  at  their 
points  of  attachment  to  the  frontal  and  superior  maxillary  bones. 
They  are  often  comphcated  by  fractures  of  the  vomer  and  perpendicular 
plate  of  the  ethmoid,  as  well  as  by  fractures  of  the  cartilaginous  septum 
of  the  nose. 

The  diagnosis  may  be  made  from  the  flattened  appearance  of  the 
nose.  By  grasping  the  nasal 
bones  between  the  index- 
fingers  of  both  hands  and 
moving  the  nose  in  a  lateral 
direction  to  and  fro  one  can 
readily  obtain  abnormal 
mobility  and  in  many  cases 
crepitus. 

.Nasal  Septum. — The 
diagnosis  of  injury  of  the 
nasal  septum  may  be  made 
in  some  cases  from  the  ex- 
ternal appearance  alone,  the 
nose  turning  well  over  to 
one  side.  This  deviation 
of  the  nose  may  involve  the 
tip  or  the  entire  nose.  There 
is  usually  considerable  in- 
terference with  respiration 
and  more  or  less  epistaxis. 

The  diagnosis  of  the  ex- 
tent of  the  injury  to  the 
septum  can  only  be  made 

by  an  examination  of  the  interior  of  the  nose  through  the  anterior 
nares.  At  times  the  septum  is  only  bent,  so  that  there  is  no  deformity 
externally.  Severe  fractures  of  the  nasal  bones  are  often  complicated 
by  fractures  of  the  anterior  fossa  of  the  skull,  so  that  the  symptoms  of 
the  latter  predominate,  and  it  is  not  until  all  swelling  of  the  eyeUds  and 
around  the  root  of  the  nose  has  disappeared,  that  the  diagnosis  of  the 
fracture  of  the  nasal  bones  is  made. 

In  fractures  of  the  nasal  bones  which  extend  into  the  frontal  sinuses, 
there  may  be  extensive  emphysema  of  the  upper  portion  of  the  face. 


Fig.  40. — Widening  of  Nose  following  Compound  Frac- 
ture OF  THE  Nasal  Bones  in  Boy  of  Ten. 


88  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

At  times  a  fracture  of  the  nasal  bones  will  be  followed  by  epiphora, 
through  involvement  of  the  nasal  ducts. 

Fractures  of  the  Malar  Bone. — ^This  bone  is  usually  fractured  at 
its  junction  with  the  superior  maxilla,  or  with  the  zygomatic  process  of 
the  temporal  bone.  A  rotation  takes  place  of  the  malar  bone,  so  that 
at  its  junction  with  the  zygomatic  process  a  distinct  depression  is  to  be 
felt,  whereas  at  its  point  of  junction  with  the  malar  process  of  the 
superior  maxilla  there  is  a  prominence  at  the  outer  third  of  the  lower 
border  of  the  orbit  (Fig.  41). 

This  deformity  may  be  reversed  if  the  blow  has  been  received  over 


Fig.  41. — Fracture  of  AIalar  Bone. 
A  frequent  seat  of  fracture  of  the  malar  bone  is  along  the  lines  shown,  namely,  at  its  junction  with  the 
superior  maxilla  and  the  zygomatic  process  of  the  temporal  bone.     The  arrows  show  the  direction  in  which 
the  fragments  composed  of  the  entire  malar  bone  are  dislocated. 

the  eye  instead  of  over  the  zygoma,  so  that  there  is  a  depression  along 
the  lower  border  of  the  orbit  and  an  elevation  along  the  zygoma. 

In  crushing  injuries  of  the  malar  bones  there  is  a  simple  flattening 
of  the  prominent  portion  of  the  cheek  normally  formed  by  the  malar 
bone. 

There  is  great  danger  in  these  fractures  of  the  malar  bone,  of  injuring 
the  orbit  or  the  infraorbital  nerve.  A  depression  over  the  zygoma  may 
cause  some  interference  with  the  use  of  the  muscles  of  mastication. 

Fractures  of  the  Superior  Maxilla. — Fractures  of  this  bone  sel- 
dom occur  alone,  being  usually  associated  with  those  of  the  other  bones 


INJURIES    OF   THE    BONES    OF   THE    FACE. 


89 


of  the  face.  They  may  simply  involve  the  alveolar  process,  which  occurs 
after  faulty  extraction  of  teeth  or  blows  upon  the  jaw.  Fractures  of 
the  body  of  the  bone  are  usually  multiple  or  comminuted. 

The  diagnosis  may  be  made  by  inspection  and  palpation  of  the  bone. 
At  times  one  may  feel  a  fissure  in  the  bone,  or  a  depression,  which  crepi- 
tates on  pressure.  The  cheek  is  sunken  in.  Examination  through 
the  mouth  shows  that  there  is  a  distinct  gap  between  two  of  the  teeth, 
and  if  the  fracture  is  a  comminuted  or  a  multiple  one,  as  is  often  the 
case,  there  is  abnormal  mo- 
bihty  and  the  teeth  are  not 
in  line  with  each  other. 

In  fractures  involving 
the  anterior  wall  of  the  an- 
trum, or  in  those  in  which 
the  fracture  line  extends  up 
into  the  frontal  sinus,  there 
may  be  some  emphysema 
of  the  upper  portion  of  the 
face. 

Gunshot  fractures  of 
the  superior  maxilla  or  in- 
juries following  the  burst- 
ing of  shells  in  war  are  not 
infrequent,  A  diagnosis 
may  be  readily  made  by  a 
direct  inspection  of  the 
wound. 

Fractures  of  the  In- 
ferior Maxilla.— The 
majority  of  these  occur 
close  to  the  canine  teeth, 
either  on  one  or  both  sides 

of  the  jaw.  They  most  frequently  follow  a  direct  force,  such  as  a  blow, 
or  a  fall  upon  the  chin.  Fractures  of  the  body  are  far  more  frequent 
than  those  of  the  ramus.     The  latter  are  comparatively  rare. 

The  diagnosis  of  a  fracture  of  the  body  is  not  difficult,  and  may  be 
made  by  grasping  the  jaw  in  the  manner  shown  in  Fig.  43  on  either  side 
of  the  fracture,  with  the  thumb  and  index-finger  of  each  hand.  One 
can  usually  obtain  a  false  point  of  motion  and  crepitus.  In  addition, 
fractures  of  the  body  reveal,  upon  examination  of  the  mouth,  an  unequal 


Fig.  42. — Hematoma  of  Face  over  Malar  Bone  Resembling 
Malignant  Growth,  on  account  of  Slow  Absorption 
OF  Blood  and  Marked  Induration. 


9° 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


position  of  tlie  teetli  on  eitlier  side  of  the  fracture  line  and  a  tear  in  the 
mucous  membrane. 

Fractures  of  the  ramus  can  be  best  felt  through  the  mouth,  by 
inserting  two  fingers  of  one  hand  far  back  into  the  mouth  toward  the 
ramus  and  manipulating  the  jaw  between  the  fingers  of  this  hand  and 
those  of  the  other  placed  on  the  outer  side  of  the  ramus.  In  some  cases 
there  is  considerable  deformity,  due  to  the  fact  that  the  masseter  muscle 
pulls  the  lower  fragment  upward,  so  that  the  fracture  hne  in  the  ramus 

can  be  distinctly  felt  through 
the  cheek  from  the  outside. 
Fractures  of  the  ramus  are 
usually  accompanied  by  con- 
siderable difficulty  in  chew- 
ing. 

In  fractures  of  the  body 
of  the  bone,  involving  the  in- 
ferior dental  canal,  neuralgic 
pains  or  anesthesia  are  often 
present,  or  there  is  a  reiiex 
lockjaw  as  a  result  of  stimu- 
lation of  the  inferior  dental 
nen-e. 

Fractures  of  the  coronoid 
process  of  the  lower  jaw  are 
extremely  rare.  Fractures  of 
the  neck  of  the  condyle  show 
a  depression  in  front  of  the 
external  meatus,  and  on  pal- 
pation the  condyle  is  not  felt 
to  follow  the  movements  of 
the  jaw.  The  chin  is  dis- 
placed toward  the  side  of  the 
injur}',  because  the  lower  fragment  is  pulled  upward  and  inward. 


Fig.  43. — Method  of  Grasping  Jaw  (Lower),  in  Order 
TO  Determint;  Fractures  of  the  Lo\^'er  Jaw. 
The  thumbs  of  both  hands  are  placed  inside  of  the 
mouth  on  either  side  of  the  fracture  hne,  the  remaining  fin- 
gers being  placed  on  the  lower  border  externally,  the  two 
fragments  are  then  moved  against  each  other  in  upward  and 
downward  directions  altematelj'. 


Dislocation  of  the  Jaw. 
These  are  usually  bilateral.  The  characteristic  position  of  the  mouth 
is  well  sho^^^l  in  Fig.  45.  The  lower  jaw  projects  in  front  of  the  upper. 
The  mouth  is  open.  There  is  a  depression  in  front  of  the  ear,  correspond- 
ing to  the  glenoid  cavity,  and  the  condyle  can  be  felt  just  below  the 
zygoma.  There  is  great  difficulty  in  deglutition,  and  the  masseter 
and  temporal  muscles  are  very  tense. 


DISEASES    OF   THE    SOFT   PARTS    OF   THE    FACE.  QI 

In  unilateral  dislocations  all  of  these  signs  are  less  marked,  the  chin 


Fig.  44. — Location  of  Most  Frequent  Fracture  Lines  of  Various  Portions  of  the  Jaw. 

I,  Fracture  of  condyloid  process  extending  into  temporo-maxillary  joint;  2,  fracture  of  ramus  of  jaw, 
3,  fracture  close  to  junction  of  ramus  and  body.  The  white  arrow  to  the  right  of  3  shows  the  direction  in 
which  the  masseter  muscle  pulls  the  proximal  fragment  upward,  and  the  arrow  to  the  left  of  the  3  shows  the 
direction  in  which  the  muscles  attached  to  the  lower  jaw  close  to  the  median  line  pull  it  downward. 


Fig.  4S. — Forward  Dislocation  of  Jaw. 
I,  Condyle   resting   upon,  or    in    front   of    articular    eminence;    2,  note  forward   displacement  of  teeth  of 

lower  jaw. 

is  pushed  over  to  the  non-dislocated  side,  and  the  above  signs   are 
present  only  on  one  side  of  the  face. 


92 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


DISEASES  OF  THE  SOFT  PARTS  OF  THE  FACE. 

Infections. 
Erysipelas  constitutes  the  most  frequent  form  of  infection  of  the 
soft  parts  of  the  face  with  which  the  surgeon  has  to  deal.     It  follows 
eczema  and  fissures  of  the  mouth,  nose,  or  ears.     It  may  begin  as  an 

erysipelatous  angina  or 
sore  throat  and  later 
spread  to  the  face.  The 
primary  pharyngeal  cases 
are  extremely  serious  and 
are  not  infrequently  fol- 
lowed by  meningitis. 

The  diagnosis  of  fa- 
cial erysipelas  does  not 
differ  from  that  of  the 
same  disease  in  other 
parts  of  the  body.  The 
chief  characteristic  is  the 
bright,  glistening  redness, 
which  causes  the  skin  of 
the  face  to  be  glazed  and 
shining.  There  is  dis- 
tinct swelling  over  the 
erysipelatous  area.  If 
the  finger  is  passed  from 
the  neighboring  healthy 
skin  across  the  boundary 
line,  one  can  notice  a  dis- 
tinct elevation  of  the  skin. 
One  can  also  feel  the 
tense  infiltration  of  the 
skin.  The  fact  that  the 
swelHng  scarcely  pits  on  pressure,  and  that  the  redness  cannot  be 
caused  to  disappear  quite  as  rapidly  on  pressure  as  in  the  case  of  the 
redness  due  to  an  ordinary  phlegmon  or  infection  of  the  subcutaneous 
tissue  serves  to  distinguish  erysipelas  from  a  phlegmon. 

The  border  line  of  the  erysipelatous  area  is  especially  to  be  observed 
where  a  question  arises  as  to  whether  erysipelas  or  an  ordinary  phleg- 
monous inflammation  is  present.  This  border  line  shows  distinct 
demarcation  from  the   healthv  skin.      It   shows   outrunners    or    pro- 


FiG.  46. — Swelling  of  the  Face  in  Erysipelas. 
In  this  case  the  swelling  over  the  eyeUds  and  edema  and 
tenderness  over  the  frontal  sinuses  were  so  marked  as  to  simulate 
a  bilateral  sinusitis. 


DISEASES    OF   THE    SOFT   PARTS    OF   THE    FACE.  93 

jections  along  its  entire  length,  giving  it  a  jagged  or  irregular  appear- 
ance. 

In  cases  of  phlegmon,  this  border  line  does  not  exist,  and  there 
is  a  gradual  shading  off  of  the  redness  of  the  skin  into  the  surrounding 
area. 

In  phlegmonous  inflammation  the  redness  is  also  of  a  darker 
reddish-blue  tint,  and  the  induration  is  more  marked  owing  to  the  in- 
volvement of  the  deeper  tissues. 

In  erysipelas  of  the  face,  as  of  the  head,  the  presence  of  numerous 
blisters  or  bullae  often  assists  in  making  the  diagnosis. 

If  the  erysipelas  involves  the  upper  portion  of  the  face  it  may  cause 
intense  svv^elling  of  the  eyelids  (Fig.  46).  The  illustration  referred  to 
was  taken  from  a  case  of  facial  erysipelas,  with  meningeal  involvement 
and  great  tenderness  over  both  frontal  sinuses,  so  that  the  cjuestion  arose, 
as  it  frequently  does,  of  whether  an  empyema  of  both  frontal  sinuses 
might  be  present  with  secondary  infection  of  the  skin.  A  frontal  sinus 
empyema  can  be  differentiated  by  the  fact  that  the  swelling  of  the 
upper  hd  is  usually  greater  than  that  of  the  lower;  there  is  more  local 
tenderness  and  the  temperature  as  a  rule  is  higher  than  it  is  in  eiysipelas. 
The  pulse  is  also  slow  as  compared  with  other  septic  infections. 

A  furuncle  of  the  nose  or  of  the  upper  lip  may  give  rise  to  a  confusion 
in  diagnosis,  since  the  redness  and  infiltration  greatly  resemble,  in  the 
earlier  stages,  that  of  the  ordinary  facial  erysipelas.  A  furuncle  can 
be  readily  differentiated  from  erysipelas  by  a  careful  search  for  a  suppu- 
rating point,  either  on  the  inside  or  the  outside  of  the  nose,  or  upon 
the  upper  lip.  In  a  furuncle  of  the  upper  hp  the  infiltration  is  usu- 
ally board-Uke  and  brawny,  and  there  is  always  considerable  involve- 
ment of  the  entire  thickness  of  the  hp,  with  edema  of  the  mucosa 
beneath  it. 

In  tjie  case  of  furuncles  of  the  nose,  especially  those  of  the  inner 
aspect,  the  diagnosis  is  much  more  difficult.  It  may  be  made  (a)  from 
observation  of  the  course  of  the  case;  (b)  from  the  fact  that  the  redness 
does  not  spread  as  rapidly  as  in  erysipelas,  and  also  by  observing  the 
pecuhar  ghstening  redness  of  erysipelas  and  the  sharply  marked  irregular 
borders  just  described. 

Mahgnant  pustule  upon  the  nose,  due  to  anthrax,  may  rarely  give 
rise  to  confusion.  This  is  also,  as  is  the  case  with  furuncles,  readily 
to  be  differentiated,  by  the  fact  that  palpation  shows  that  the  swelling 
of  anthrax  is  very  firm,  and  that  there  is  a  central,  depressed  scar.  A 
bacteriological  examination  of  the  pus  will  readily  serve  to  distin- 
guish the  anthrax  infiltration  from  an  erysipelas. 


94 


SURGICAL    AIPECTIOXS    OF    THE    HEAD. 


When  en-sipelas  is  complicated  by  meningitis  there  is  accompanying 
dehrium,  the  pulse  and  temperature  both  rise,  and  there  are  the  other 
s\Tnptoms  of  infective  meningitis  referred  to  on  page  56. 

Furuncles  of  the  Face. — ^There  is  usually  no  difficulty  in  making 
a  diagnosis  of  a  furuncle  of  the  face,  OT^Tng  to  the  fact  that  the  soft  parts 
around  the  original  atrium  of  infection  are  densely  infiltrated  and  the 
swelhng  is  board-hke  in  consistency. 

In  furuncles  of  the  side  of  the  nose  there  is  often  quite  marked  edema 
of  the  eyehds  and  adjacent  portions  of  the  cheek.  In  furuncles  of  the 
upper  Hp  the  swelling  is  at  times  enormous,  and  the  diagnosis  may  be 

readily  made  from  the  location  of 
the  swelhng  and  the  detection  of  a 
pus  focus.  In  the  later  stages  there 
is  distinct  fluctuation  present. 

The  onset  of  compHcations  of 
furuncles  of  the  face,  especially  of 
the  upper  lip,  such  as  a  thrombo- 
phlebitis of  the  facial  vein,  result- 
ing in  a  thrombosis  of  the  cavern- 
ous sinus,  may  be  suspected  vi'hen 
the  veins  become  markedly  dilated 
toward  the  inner  angle  of  the  eye 
or  root  of  the  nose,  accompanied 
by  swelling.  This  is  soon  followed 
by  the  ordinar}-  signs  of  thrombosis 
of  the  cavernous  sinus,  both  local 
and  constitutional,  referred  to  on 
page  85  (see  Fig.  2^). 

^Meningitis  as  a  compKcation  of 
furuncles,  and  other  forms  of  infec- 
tion caused  by  the  ordinary-  pyo- 
genic organisms  in  the  face,  may 
be  suspected  by  the  persistence  of  fever,  increase  of  pulse- rate,  dehrium, 
stupor,  and  other  symptoms  of  an  infective  meningitis. 

Extensive  phlegmons  of  the  soft  parts  of  the  face,  extending  do-^Ti 
to  the  neck,  may  occur  secondar}^  to  periosteal  abscesses  due  to  carious 
teeth,  or  rarely  after  a  suppuration  of  the  lymph-nodes  situated  within 
the  substance  of  the  cheek.  The  diagnosis  can  be  made  from  the  exten- 
sive swelling  and  other  signs  of  deep-seated  infection,  such  as  high  tem- 
perature and  pulse-rate,  local  redness,  etc.  In  even,'  such  case  the  mouth 
should  be  inspected  at  once,  as  this  is  the  source  in  the  majority. 


Fig.  47.— Swelling  of  Lip  rs"  a  Case  of  Fur- 
uncle OF  THE  Lower  Lip. 
The  black  area  along  the  lower  edge  of  the  ver- 
mihon  surface  indicates  the  purulent  focus. 


DISEASES    OF   THE    SOFT   PARTS    OF   THE    FACE. 


95 


In  phlegmons  of  the  deeper  structures  of  the  face  there  may  be 
thrombophlebitis  of  the  pter}'goid  veins  (Fig.  25),  which  may  spread  to 
the  cavernous  sinus,  causing  infective  thrombosis  of  this  structure,  with 
all  of  the  characteristic  signs  of  this  condition. 

Infection  of  the  soft  parts  of  the  face  may  spread  to  the  interior  of 
the  orbit,  and  the  question  may  at  times  arise  as  to  whether  a  throm- 
bosis of  the  cavernous  sinus  is  present,  or  an  orbital  phlegmon.     In  the 
latter  disease,  there  is  less 
dilatation     of     the    supra- 
orbital, angular,  and  frontal 
veins.     The  headache  is  su- 
praorbital, rather  than  deep- 
seated.      In    both     condi- 
tions the  exophthalmos  and 
swelling  of  the  lid  and  con- 
junctiva are  quite  marked. 
There  is  choked  disc  or  op- 
tic neuritis  in  a  sinus  throm- 
bosis. 

In  orbital  phlegmon,  on 
the  other  hand,  the  changes 
in  the  fundus  are  but  Kttle 
marked. 

Noma. — ^The  diagnosis 
of  noma  may  be  made  from 
the  fact  that  it  accompanies 
either  the  infectious  dis- 
eases, such  as  measles, 
scarlet  fever  and  typhoid, 
or  marantic  conditions  in 
adults  or  children.  It  be- 
gins on  the  mucosa  of  the 

cheek  or  hp  as  a  vesicle,  but  is  soon  followed  by  a  black  slough,  whose 
situation  is  usually  on  the  inner  side  of  the  cheek  and  extends  through 
the  entire  thickness  of  this  part  of  the  face.  It  is  comphcated  by  severe 
septic  disturbances,  about  70  per  cent,  of  the  cases  dying  of  sepsis. 
There  is  usually  no  difficulty  in  diagnosis,  when  one  considers  the  ac- 
companying diseases  or  conditions  and  the  characteristic  sloughing  and 
septic  symptoms. 

Lupus. — ^I.upus  vulgaris  exists  more  frequently  on  the  face  than  in  any 
other  part  of  the  body.     It  involves  especially  the  nose,  the  lips  and  the 


Fig. 


-Blastomycotic  Disease   of  the  Skin   of  the 

Face. 
Observe  the  typical  wart-like  elevations. 


96 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


cheeks,  and  is  irregularly  scattered  over  these  parts.  It  destroys  thetipand 
wings  of  the  nose,  and  through  its  cicatrization  may  produce  ectropion. 
The  diagnosis  may  be  made  from  the  presence  of  raspberry-red, 
pinhead-size  nodules  situated  just  beneath  the  epidermis.  At  times  it 
is  followed  by  carcinoma,  which  may  be  suspected  when  a  papilloma- 
tous change  takes  place  in  the  lupus  area,  with  gradual  extension  of 
induration  (Fig.  49). 

Syphilis. — ^This  rarely  appears  as  a  primary  form,  except  upon  the 
Hps  (page  105).     The  chief  form  of  surgical  interest  is  the  tertiary  or 

gummatous  ulceration  which 
may  be  mistaken  for  a  begin- 
ning epithelioma  of  the  face. 
It  appears  in  the  form  of 
round  and  serpiginous  ulcer- 
ations, not  infrequently  multi- 
ple, which  are  situated  upon 
the  cheeks,  especially  at  the 
junction  of  the  nose  and 
cheeks. 

A  diagnosis  can  be  made 
from  the  history  of  a  preced- 
ing syphilitic  infection,  by  an 
examination  of  the  remainder 
of  the  body,  and  from  the  char- 
acteristic appearance  of  the 
broken-down  gummata  them- 
selves. The  outline  of  the 
ulcers  is  often  serpiginous  or 
round,  the  borders  are  not 
elevated,  as  in  the  case  of  a 
carcinoma,  the  induration  is  moderate,  and  not  to  be  compared  with 
that  of  the  ordinary  form  of  epithehoma.  The  edges  are  quite  steep,  as 
if  cut  out  with  a  die,  and  the  floor  of  the  ulcer  is  covered  with  flabby 
granulations  and  necrotic,  sloughing  masses.  There  is  usually  but  httle, 
if  any,  enlargement  of  the  cer\ical  lymph-nodes.-  Tertiaiy  syphilitic 
ulcers  are  also  frequent  upon  the  forehead,  where  they  are  associated 
with  necrosis  of  the  frontal  bone  (Fig.  30). 

A  differentiation  from  the  slow-growing  form  of  epithelioma,  also 
called  rodent  ulcer,  may  be  made  by  the  fact  that  this  latter  process 
shows  but  Httle  induration  of  the  edges  or  tendency  to  ulceration  in  the 
earlier  stages.     Its  course  is  very  chronic,  so  that  the  breaking  down  of 


Fig.  49. — Epithelioma  of  the  Face  Developing  on 
Lupus  Vulgaris. 
Observe  how  the  alae  nasi  have  been  destroyed  by 
the   long-existing   lupus:   L,    Lupus   nodules;    £,  cauli- 
flower-Uke  epithelioma. 


DISEASES    OF   THE    SOFT   PARTS    OF   THE    FACE. 


97 


tissue  progresses  very  slowly,  one  portion  showing  cicatrization  while 
another  shows  ulceration,  and  there  is  an  absence  of  a  history  of  pri- 
mary syphihtic  infection. 

Actinomycosis  of  the  Face. — ^This  usually  causes  one  of  two  con- 
ditions, (a)  soft  nodules,  which  fluctuate  distinctly  and  sooner  or 
later  break  down,  giving  rise  to  sinuses  from  which  a  brownish  pus  is 
discharged,  and  containing  actinomyces.  These  latter  organisms  can 
be  recognized  by  the  naked  eye  as  fine,  yellowish  granules. 

(b)  If  the  disease  is  more  extensive  it  causes  an  infiltration  of  the 
deeper  tissues  of  the  face,  especially  of  the  masseter  muscle,  giving  rise 
to  a  board-like  hardness,  resembling  a  sarcoma  until  softenins:  occurs. 


Fig.  so. — Front  View  of  Saddle-nose  Due  to 
Tertiary  Syphilis. 
Note  that  the  falling-in  has  taken  place  at 
the  lower  end  of  the  quadrilateral  nasal  carti- 
lages, owing  to  destruction  of  the  cartilaginous 
septum  nasi.  - 


Fig.  si. — Side   View  of   Saddle-nose   Caused 
BY  Tertiary  Syphilis. 
Note    the   beginning   of    depression    at    the 
level  of   the  lower  portion  of  quadrilateral  nasal 
cartilages. 


Actinomycosis  should  be  thought  of  whenever  abscesses  recur  in  the 
face  from  time  to  time,  and  there  is  an  absence  of  suspicion  of  tuber- 
culosis. One  should  never  neglect,  under  these  circumstances,  espe- 
cially if  there  is  the  history  of  a  recurring  dental  abscess,  to  search  for 
the  actinomyces. 

The  question  may  arise  of  making  a  dift'crcntial  diagnosis  between 
actinomycosis  and  syphiHs.  In  actinomycosis  there  are  pockets  of  pus, 
or  undermined  ulcers,  filled  with  flabby  granulations  and  surrounded 
by  smaller  or  larger  abscesses.  Syphihs  can  be  differentiated  by  not 
finding  the  organisms  of  actinomycosis  and  by  the  sloughing  condition 
7 


98 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


of,  the  floors  of  its  ulcers.  The  edges  of  the  latter  are  quite  steep  and 
sharply  cut. 

Symmetrical  Disease  of  the  Lachrymal  and  Salivary  Glands. — 

This  disease,  which  was  first  called  "Mikulicz's  disease,"  consists  in 
an  infiltration  of  the  connective  tissue  of  the  lachrymal  and  saHvar\" 
glands  on  both  sides  of  the  face  with  lymphoid  cells.  The  tumors  are 
quite  firm,  there  are  no  inflammator}-  symptoms,  and  the  diagnosis  can 
be    made    from    the    symmetrical    enlargement     of    the    laclir}TTLal, 

parotid,      and      submaxillar}- 

glands. 

It  belongs  to  the   class  of 

infectious  diseases,  and  bears 

some  relation  to  the  leukemic 

processes. 

Neoplasms  of  the  Face, 
benign  tumors  of  the  skin  of 

THE  FACE. 

Angiomata.  — The  most 
frequent  benign  form  is  the 
capillar}^  nevus,  which  may 
show  itself  as  one  or  more 
small,  raspberr}'-red,  sHghtly 
elevated  soft  areas.  It  may 
involve  an  entire  half  of  the 
face.  It  may  combine  with  a 
second  form  of  vascular  tumor, 
in  which  the  veins  are  involved, 
the  so-called  venous  form  of 
angioma,  or  this  latter  form 
may  exist  alone.  It  they  are 
combined,  the  diagnosis  may  be  made  from  the  fact  that  the  swelhng 
is  much  greater  than  would  exist  in  the  case  of  an  ordinar}^  nevus  in- 
volving only  the  capillaries;  that  the  whole  mass  can  be  caused  to  dis- 
appear on  pressure,  but  returns  readily  to  its  original  size  (Fig.  53). 
It  increases  in  size  when  the  child  cries. 

If  the  venous  form  exists  alone,  the  tumors  are  quite  soft,  the  skin 
over  them  is  bluish  in  color,  and  the  entire  tumor  can  be  caused  to 
disappear  upon  pressure,  but  recurs  as  soon  as  the  pressure  is  rehevcd. 
They  are  often  associated  with  lipomata,  especially  in  the  parotid 
region,  and  this  combination  should  be  suspected  when  the  tumors  are 


Fig.  52. — Nasal  Deformity  Due  to  Syphilis. 
In  this  case  the  cartilaginous  and  bony  septum  was 
completely  destroyed,  allowing  the  nose  to  fall  in,  and  the 
two  nostrils  to  become  fused  into  one  opening.     There  is 
scarcely  any  trace  of  the  ate  nasi. 


DISEASES    OF   THE    SOFT   PARTS    OF   THE    FACE. 


99 


much  larger  than  could  be  accounted  for  by  the  presence  of  a  venous 
angioma  alone. 

Angiomata  involving  the  arteries  (cirsoid  aneurysm)  occur  in  the 
frontal  and  occipital  regions.  Their  characteristics  were  referred  to  in 
the  description  of  the  same  condition  in  the  temporal  region  of  the 
scalp  (page  68). 

Traumatic  aneurysms  are  quite  rare  in  the  face  and  show  the  same 
signs  as  elsewhere. 

Sebaceous  cysts  are  not  as  frequent  in  the  face  as  in  the  scalp  and 
show  some  differences.  They  are  usually  adherent  to  the  skin,  are 
rounded,  cause  less  eleva- 
tion of  the  skin  overlying 
it,  are  less  firm,  and  show 
more  fluctuation  than  is  the 
case  in  similar  tumors  of  the 
scalp. 

Lipomata. — ^These  oc- 
cur in  the  forehead  or  deep- 
ly in  the  tissues  of  the  cheek. 
In  the  latter  position  they 
may  be  of  slow  development 
and  must  be  differentiated 
from  chronic  tubercular  ab- 
scesses and  cystic  tumors. 
This  can  be  done  by  the 
fact  that  they  are  much 
more  apt  to  be  lobulated  in 
structure  and  the  fluctua- 
tion is  very  indistinct. 

Dermoid  Cysts. — 
These  are  found  in  the  outer 

fourth  of  the  upper  eyehd,  less  frequently  at  the  inner  canthus  or  at  the 
root  of  the  nose.  They  can  be  readily  distinguished  from  sebaceous 
cysts  by  the  fact  that  they  are  not  adherent  to  the  skin,  are  usually  im- 
movable upon  the  skull,  and  by  their  characteristic  location.  Their  dif- 
ferentiation from  meningocele  was  considered  on  page  67,  in  connection 
with  the  latter  form  of  swcUing. 

Fibroma  molluscum  occurs  on  the  face  usually  in  connection 
with  the  same  condition  elsewhere. 

Adenomata  of  the  sweat  and  sebaceous  glands  occur  especially 
around  the  sides  of  the  nose,  as  soft,  flat  tumors,  which  may  become 


Fig.  53. — Angioma  of  the  Parotid  Region. 


lOO 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


pedunculated  and  bleed  readily.  They  occur  above  middle  age  and 
are  much  softer  and  slower  in  their  growth  than  epithehomata. 

Lymphangiomata  usually  occur  in  the  cavernous  form  in  the  cheeks. 
They  may  form  enormous  tumors,  which  penetrate  the  entire  thickness 
of  the  cheek  and  hang  down  as  soft  masses  almost  to  the  middle  of  the 
neck.  They  occur  most  frequently  in  children  and  may  be  differenti- 
ated from  the  venous  forms  of  angioma  by  the  absence  of  the  peculiar 
bluish  color  of  the  skin,  and  the  fact  that  the  hemangiomata  seldom 
reach  the  size  of  the  lymphangiomata  (Figs.  54  and  55). 

Malignant  Tumors  of  the  Skin  of  the  Face. — ^These  include 
carcinomata  and  sarcomata.     Carcinoma  appears  as  a  primar}^  form, 


Fig.  54. — Anterior  View  of  Case  of  Lymphan- 

GIOilA  OF  THE  ChEEK. 


Fig.    55. — Side    View    of    Lymphangioma    of 
Cheek.    Same  Case  Shown  in  Fig.  54. 


either  as  a  rodent  ulcer  or  as  the  ordinary  type  of  epithehoma.  The 
characteristics  of  the  rodent  ulcers  are  that  it  first  forms  a  crust  and  then 
a  flat  ulcer,  which  cicatrizes  here  and  there.  Its  growth  as  a  rule  is 
very  slow,  but  at  times  it  may  take  on  a  more  mahgnant  form  and  cause 
extensive  ulceration,  destroying  all  the  tissues  in  its  path  (Fig.  56).  In 
its  earHer  stages,  when  it  exists  as  a  flat  ulceration,  it  must  be  differen- 
tiated from  the  flat,  ulcerating  forms  of  lupus.  This  can  be  readily 
done  by  the  fact  that  the  ulcers  of  lupus  usually  show  undermined  edges, 
and  there  are  evidences  of  lupus  elsewhere  on  the  face.  From  syphihs 
it  can  be  distinguished  by  the  fact  that  the  edges  of  a  syphihtic  ulcer  are 
quite  sharp  or  steep,  there  is  more  sloughing,  and  there  is  either  the 
history  or  the  presence  of  syphihs  elsewhere. 


DISEASES    OF   THE    SOFT    PARTS    OF   THE    FACE, 


lOI 


Ordinary  epithelioma 
appears  comparatively 
rarely  on  any  other  part 
of  the  face  except  the  lips 
(Fig.  57),  and  this  will  be 
considered  later.  As  a 
secondary  form  it  may  be 
the  result  of  the  extension 
of  carcinomata  from  the 
jaws  or  interior  of  the 
mouth. 

Sarcoma  appears 
chiefly  as  the  pigmented 
variety  or  melanosar- 
coma,  arising  from  the 
pigmented  moles  which 
are  so  frequently  present 
in  the  face. 


Trigeminal  Neuralgia. 
The  diagnosis  of  this 

disease  can  be  made  from 

the  history  of  constant  or 

recurrent  pains  in  a  portion  of,  or  over  the  entire  area  of  distribution  of 

the  trigeminal  nerve.  The 
pains  are  Hghtning-Hke,  begin- 
ning after  the  least  irritation. 
At  first  the  intervals  are  of  con- 
siderable duration,  but  later 
these  become  shorter,  until  the 
pains  are  almost  continuous. 
The  diagnosis  may  be  made 
from  the  fact  that  the  pains 
occur  at  first  along  one  fila- 
ment, and  later  along  all  of 
the  branches  of  the  trigeminal 
nerve.  In  addition,  there  is 
usually  pain  on  pressure  over 
the  points  of  exit  of  the  three 
principal     branches     of     the 

Fig.  sy.-iipiTHELioMA  OF  Skin  OF  Face  Just  Below       nervc,  Supraorbital,  inf raorbi - 

AND  Involving  Lower  Eyelid.  '         J- 


Fig.  56. — Extensive  Destruction  of  Face  in  Case  of  Epi- 
thelioma, Exposing  Left  Side  of  Bone,  etc. 
T,  Middle  turbinated  bone. 


I02 


SURGICAL   AFFECTIONS    OF   THE    HEAD. 


tal,  and  mental.     This  can  be  elicited  by  moderate  pressure  over  the 
nerves  at  their  points  of  exit  (Fig.  4). 


Fig.  58. — Double  Harelip  and   Cleet  Palate  in  Newborn  Child. 
Associated  with  microcephaly  and  supernumerary  digits.     Note  the  protruding  intermaxillary  bone  and  ihe 

skin  covering  it. 


Fig.  sq. — Congenital  Supernumerary  Digit  on  Each  Hand  in  a  Newborn  Babe. 
This  child  also  had  six  toes  on  one  foot,  and  a  double  harelip  and  cleft  palate,  as  shown  in  Fig.  58. 


DISEASES    OF   THE    SOFT    PARTS    OF    THE    FACE. 


103 


In  searching  for  a  cause,  one  should  consider  whether  the  disease 
is  of  peripheral  or  central  origin.  If  of  peripheral  origin  there  is  usually 
the  history  of  the  disease  having  begun  in  one  branch  of  the  nerve  and 
later  involved  the  other  branches. 

One  must  search  for  peripheral  causes,  such  as  carious  teeth,  diseases 
of  the  jaw  bones,  tumors,  chronic  empyema  of  the  frontal  sinus  or 
antrum,  fractures  and  various  constitutional  causes,  such  as  chlorosis, 
toxemia  from  malaria,  or  syphihs. 

Among  the   central   causes   may  be  mentioned   cerebral  syphihs, 
aneurysm   of   the   in- 
ternal carotid  artery, 
and     tumors    of    the 
brain. 

If  both  central  and 
peripheral  causes  are 
eliminated,  the  disease 
is  in  all  probabihty  a 
reflex  one. 


Diseases    of    the 
Mouth  and 

Palate. 
Malformations  of 
the  Lips. — ^The  most 
common  congenital 
malformation  of  the 
lip  is  harehp.  The 
diagnosis    of    this    is 


Fig.  60. — Double  Cleft  Palate  and  Harelip. 
View  of  interior  of  mouth:  P.  Skin  in  median  line  covering  the 
intermaxillary  bone,  the  projecting  portion  of  the  latter  being  seen 
immediately  below  it;  M ,  intermaxillary  bone;  C,  C,  palatal  processes 
of  the  right  and  left  superior  maxillae  respectively;  the  black  space 
between  C  and  M  on  each  side  of  the  median  line  represents  the  cleft 
in  the  palate;  L,  L,  right  and  left  lips  respectively.  Note  the  cleft 
between  these  ruchmentary  lips  and  the  central  portion  of  the  lip  (P) , 
covering  the  intermaxillary  bone.  T,  Tongue.  This  photograph  was 
taken  while  the  child  was  crying. 


easy  (Fig.  58).    It  may 

involve  simply  the  vermilion  or  red  border  of  the  lip,  or  extend  through 
the  entire  thickness  of  the  hp,  either  on  one  or  both  sides  of  the  median 
line.  If  unilateral  it  is  usually  found  on  the  left  side.  It  causes  a 
widening  of  the  nostril  of  the  corresponding  side.  If  bilateral,  there 
is  associated  with  it  the  most  frequent  congenital  malformation  of 
the  palate,  viz.,  cleft  palate  (Figs.  58  and  60).  In  such  cases  the  inter- 
maxillary bone  separates  the  double  cleft  in  the  palate  and  may  project 
between  the  two  clefts  in  the  Hps,  being  covered  by  a  flap  of  skin,  which 
is  continuous  with  that  of  the  median  line  of  the  nose.  In  many  cases 
the  intermaxillary  bone  is  markedly  prominent. 

Acquired  malformations  of  the  lips  most  frequently  follow  extensive 


I04 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


bums  or  operations.     In  many  cases  the  opening  of  the  buccal  cavity 
is  very  narrow,  giving  rise  to  a  condition  Icnown  as  microstomia. 


THE  LIPS. 

The  most  frequent  conditions  calling  for  diagnosis  in  the  lips  are 

herpes,  enlargement  of  the  hps  (macrolabia),  and  ulcerations  of  the  lip, 

due  to  syphihs,  carcinoma,  benign  and  mahgnant  warts,  or  papillomata. 

In  regard  to  herpes,  the  chief  point  of  interest  is  the  fact  that  it 

usually  occurs  at  the  angle  of  the 
mouth,  consisting  of  a  group  of 
vesicles  which  are  often  sym- 
metrically situated  on  both  lips. 
When  ulcerated,  that  is,  when  the 
vesicles  burst,  they  may  be  mis- 
taken for  either  primar}^  or  secon- 
dary syphihs.  This  will  be  re- 
ferred to  below. 

Macrolabia  may  be  due  to 
one  of  three  conditions:  {a)  In 
tuberculous  children  the  lip  is 
often  greatly  thickened  and  is 
accompanied  by  more  or  less  in- 
flammatory signs.  The  condition 
is  a  chronic  one,  growing  slowly 
in  size  until  the  lip  is  greatly  in- 
creased in  thickness,  and  recur- 
ring from  time  to  time,  (h)  In 
abnormal  thickening  of  the  lip 
due  to  lymphangioma,  the  lip 
is  fairly  firm,  the  enlargement  is 
uniform,  there  is  more  or  less  con- 
nective tissue  formation,  and  the 
enlargement  involves  the  entire  thickness  of  the  lip.  (c)  A  third  form 
of  macrolabia  is  that  due  to  a  primary  adenoma  of  the  mucous  glands 
of  the  lip.  The  lip  is  soft,  the  enlargement  is  most  marked  in  the  upper 
lip  (Fig.  6i),  and  often  one  can  feel  a  series  of  shot-like  nodules 
through   the   stretched  mucous  membrane. 

Both  hemangioma  and  lymphangioma  are  usually  congenital  con- 
ditions or  appear  in  early  infancy.  Tuberculosis  of  the  upper  ,  re- 
spiratory  tract  is   associated  with    evidences    of    the    same    disease 


Fig.  6i. — Enlargement  of  the  Lips  Due  to 
Adenomata  of  the  Mucous  Glands  (Mac- 
rolabia). 

The  enlargement  is  most  marked  in  the  upper 
Hp  on  either  side  of  the  depression  seen  in  the  median 
line.     In  addition,  this  patient  had  a  double  ptosis. 


THE    LIPS. 


105 


the 
ary 
ing 


elsewhere,  in  the  form  of 
What  was  formerly  called 
scrofulous  thickening  of 
the  lip  is  rarely  seen  at 
present  day.  Prim- 
adenomatous  thicken- 
occurs  after  puberty. 
Ulcerations  of  the  hp  are 
usually  due  to  either  syph- 
ihs  or  carcinoma. 

Syphilitic  ulcerations 
are  present  either  in  the 
form  of  primary  chancres 
or  as  broken-down  gum- 
mata.  In  the  case  of  chan- 
cres, one  finds  an  ulcer 
with  steep  edges;  there  is 
marked  induration  around 
the  edges,  the  floor  is  cov- 
ered with  a  dirty  slough  or 
necrotic  granulations,    and 


tubercular    glands    of     the    neck,   etc. 


Fig.  62. — Method  of  Everting  Lower  Lip  in  Order  to 
Observe  a  Carcinoma  of  the  Warty  Type  of  the 
Inner  Aspect  of  the  Lip. 


Fig.  63. — Ephithelioma  of  Lip  in  a  AL\n  of  Thirty-two. 
Showing  extensive  destruction  on  inner  aspect.    Lip  has  been  artificially  everted. 


io6 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


the  process  is  usually  quite  limited,  invohing,  however,  almost  the 
entire  thickness  of  the  lip  at  the  vermilion  border.  It  is  accompanied  by 
rapid  enlargement  of  the  submental  and  submaxillary  lymph-nodes  on 
the  side  of  the  hp  upon  which  the  chancre  is  situated.  The  induration 
is  never  as  marked  as  in  carcinoma.  Chancre  appears,  as  a  rule,  in 
younger  persons,  and  the  further  observation  of  the  case  with  the  appear- 
ance of  secondary  symptoms  will  soon  clear  up  the  diagnosis.  It  may 
be  stated  that  the  enlargement  of  the  lymph-nodes  in  chancre  of  the  Kp 


Fig.  64. — Extensive  Destruction  or  Lower 
Lip  Caused  by  Epithelioma,  in  a  Patient 
Sixty  Years  of  Age. 


Fig.  6s. — Epithelioma  of  Lower  Lip;  Same 
Patient  as  Shown  in  Fig.  64. 
This  illustration  shows  the  most  frequent 
localization  of  the  regional  lymphatic  infection, 
namely,  in  the  submaxillary  (i)  and  submental 
(2)  lymph-nodes. 


is  far  greater,  as  a  rule,  than  in  carcinoma,  with  which  it  may  be  con- 
fused in  some  cases,  but  the  lymph-nodes  themselves  are  not  as  firm 
and  indurated,  but  are  softer  in  consistency.  The  question  may  at 
times  arise  as  to  whether  an  ulcer  of  the  hp  is  due  to  the  ulceration  of 
the  vesicles  of  a  herpes  labiaHs.  In  the  latter  case  there  is  no  induration, 
and  recovery  should  occur  within  one  to  two  weeks  under  ordinary 
treatment. 

Gummata  of  the  hp  appear  quite  rarely,  but  must  be  borne  in  mind 
in  considering  the  differential  diagnosis  of  carcinoma  of  the  Hp.     Gum- 


THE   LIPS. 


107 


mata  are  not  accompanied  by  any  enlargement  of  the  lymph-nodes  and 
are  painless.  The  infiltration  often  involves  the  entire  hp,  although 
the  ulceration  may  be  quite  locahzed.  There  is  not  the  marked  indura- 
tion which  is  characteristic  of  carcinoma,  and  a  week  of  administra- 
tion of  the  iodid  of  potassium  in  moderate  or  large  doses  will  soon 
clear  up  any  doubts  in  diagnosis. 

Epithelioma  of  the  lip  may  appear  in  a  number  of  different  forms — 
first,  as  a  wart  (Fig.  63),  whose  base  becomes  indurated,  the  papillom- 


Fic.    66. — Method  of  Examination  in  Order  to  Determine    Enlargement  of  the  Submaxillary 

OR    Submental  Lymph-nodes. 
The  examiner  should  stand  in  front  of  the  patient,  or  both  may  be  seated  face  to  face.     The  patient  should 
be  instructed  to  relax  the  muscles  which  pass  from  the  lower  jaw  to  the  hyoid  bone  by  flexing  the  head  upon  the 
neck,  while  the  finger-tips  of  the  examining  hand  are  inserted  for  a  considerable  distance  further  than  if  the  head 
were  extended. 


atous  surface  rapidly  enlarging,  and  the  induration  extending;  second, 
it  may  appear  as  an  ulcer  which  shows  the  following  characteristic  signs : 
it  involves  the  entire  thickness  of  the  hp  (Fig.  64);  its  edges  and  base 
are  markedly  indurated;  there  is  no  necrotic  sloughing  floor,  as  in  a 
gumma  or  chancre.  An  examination  of  the  submental  and  submax- 
illary lymph-nodes  (Figs.  65  and  66)  will  show  an  enlargement  of  these 
nodes  at  a  comparatively  early  period  in  carcinoma.  In  gummata 
there  is  no  enlargement,  while  in  chancres  they  are  softer  and  larger. 


Io8  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

Carcinoma  of  the  lip  almost  invariably  invades  the  lower  lip  and 
occurs  most  often  in  men;  only  3  in  350  cases  occurred  in  females. 

Diseases  of  the  Jaws. 

TUMORS. 
The  most  frequent  tumors  which  must  be  considered  in  making  a 
diagnosis  are: 

Bexigx.  Maligxant. 

Dentigerous  cysts.  f  (a)  True  epulis. 

Odontomata.  i    (b)   Chondro-  or  osteosar- 

Cystadenomata.  j  comata  (myelogenous 

Osteomata.  i  and  periosteal). 

„.,  /  Central.  f  (a)  Arising       from       the 

X  iDrorn.3,t3,  ^  -i-^     .  i  i 

[  Periosteal.  gums. 

Chondromata.  Carcinomata .  ■{    (6)   Arising  from  the  mu- 

Granulomata    or    granulation-tissue  i  cous  membrane  of  the 

tumors.  [  antrum  of  Highmore. 

The  chief  points  of  differential  diagnosis  between  the  different 
forms  are  shown  on  page  109. 

Benign  Tumors  of  the  Jaws. 

Dentigerous  Cysts. — ^The  appearance  of  a  semifluctuating  unila- 
teral tumor  on  the  outer  side  of  the  upper  or  low^er  jaw  of  a  child  between 
seven  and  ten  years,  should  lead  to  the  suspicion  of  a  dentigerous  cyst. 
They  develop  in  connection  with  the  eruption  of  the  permanent  teeth, 
and  contain  either  a  rudimentary  or  fully  developed  permanent  tooth. 
The  outer  surface  feels  hke  a  freshly  broken  egg  shell,  giving  a  pecuhar 
crackling  sensation,  and  the  contents  of  the  cyst  is  a  clear  mucoid  fluid. 
In  the  lower  jaw  they  protrude  externally,  while  in  the  upper  they  may 
bulge  into  the  antrum.  At  times  they  appear  in  children  as  a  recurrent 
dental  abscess  which  does  not  heal  until  the  sac  is  extirpated  and  the 
permanent  tooth  removed.  Under  these  conditions  they  may  even 
penetrate  the  cheek  hke  ordinary  dental  abscesses  of  the  upper  jaw 
(Fig.  75).  As  a  rule,  they  grow  slowdy,  but  may  develop  to  the  size  of  a 
walnut  within  a  few  days. 

The  diagnostic  features  are  the  age,  development  on  outer  side  of 
jaw,  semifluctuation,  and  egg-shell  crackhng. 

They  must  be  differentiated  from  the  following: 

(a)  Sarcoma. — ^The  growth  is  more  rapid;  they  break  through  the 
bone  shell  early,  and  one  feels  the  soft  tumor  mass,  if  of  the  soft  variety. 
If  of  the  chondro-  or  osteosarcomatous  type,  there  is  no  difl&culty  in 
differentiation  because  these  are  much  firmer  than  a  dentigerous  cyst. 


TUMORS. 


109 


(b)  Fibroma. — ^The 
diagnosis  from  denti- 
gerous  cysts  must  be 
taken  into  consider- 
ation, both  in  central 
and  periosteal  fibro- 
mata. The  latter  are 
quite  rare,  and  are 
much  smaller  and 
firmer  than  the  cyst. 
Central  fibromata 
cannot  be  diagnosed 
until  the  bone  begins 
to  be  expanded  (Fig. 
68).  The  growth  is 
quite  slow,  and,  if 
there  is  only  a  shell 
of  bone  covering  it, 
one  does  not  get  the 
semifluctuant  sensa- 
tion of  a  dentigerous 
cyst,  the  tumor  f  eehng 
much  firmer.  In  case 
of  doubt  an  explora- 
tory puncture  and  the 
absence  of  fluid  can  be 
demonstrated.  Again, 
an  rv;-ray  picture  will 
show  a  shadow  corre- 
sponding to  the  tooth, 
lying  in  the  sac,  in  the 
case  of  a  dentigerous 
cyst. 

Odontomata. — 
Odontomata  are  either 
soft  or  very  hard.  The 
soft  forms  are  myxo- 
matous, like  jelly  in 
consistency  or  firmer 
like  fibrous  tissue. 
The  hard  forms  have 


u 
z 

H 

Z 

0 

u 

a 

0 

P 

s 

CO 

-6 

a 

0 

1-4 

> 

in 

0       1 

s     i 

tn          i 
0 

U.    . 
"   d 

tj 

,  r  >- 

0  t" 
CO 

1) 

4) 

..  d 

T3.0 
1^ 

Lymph-node 
Involvment. 

None. 

\ 

a 
0 

1) 
d 
0 

d 
0 

6 
d 
0 

0' 
d 
0 

6 
0 

d 
0 

d 

Rate  of  Growth. 

Slow,      rarely- 
rapid. 

1 

2 

Oh 

_0   bjo 
Zn 

CO 

.00 

1 

CO 

1 

CO 

:2 

:2 

CI, 
d 
P^         ■ 

i 

t/2 

13 

a 

13 
S 

bD 
It 

13 
6 

S 

do 
,7  M 

^         0 
d             Cl.  0       -d    en 

CO        w         h 

w  a 
Wo 

C 
0 

i 

0 

0 

6 
d 
0 

13 
1 
d    . 

ai    • 

d 

0 

d 

d 
0 

Most  Frequent 
Location. 

More    frequent  in 
lower  jaw. 

i)            1=1 

1       1 

■          ■         C               ^ 

cs                 ^     ^    .t;          u  u    ,^ 
f§     ^3       jpJl  ^H  ,g         C       pq 

> 

d 
t3 

0 
<; 

t3 
C 

CI 
-|      • 

Its 
1   d 

i    nj 
vO 

H 

C3 
4) 

<U          fe      . 

S     S  ^ 

(73    ■   W 

0 

d 

OJ 

u 

M 

d 

in 

d 
0 

tn 

1-1 

&, 
bC 

d 

1 

s    '1 

0 

«           0 

p         £  0 

0             HJ  VO 

', 

>^ 

V 

tn 

3 
0 

1- 
0 

C 

1    Q 

g 

0 

0 

£ 

s 

!   tn 
1    ^ 

!u 

S 
0 

0 

P 
d 

0 

1 

S 

2 

-S 

s 

0 
u 

-§ 

0 

£ 
C 
u 
I-. 
a 

;  CO 

P 
5 

'0 

u 

no  SURGICAL    AFIECTIOXS    OF    THE    HEAD. 

the  consistency  of  the  normal  tooth.  Both  forms  occur  during  the 
eruption  of  the  permanent  teeth,  especially  the  third  molar  or  wisdom 
teeth.  The  softer  varieties  may  resemble  a  sarcoma  but  are  much 
slower  in  growth  and  cause  no  pain.  The  harder  forms  are  always 
found  at  the  neck  of  the  tooth  and  are  irregular  in  outhne. 

Cystadenomata. — This  form  of  new  growth  is  analogous  in  structure 
to  the  multilocular  cysts  of  the  ovary.  They  arise  from  the  epithelium- 
containing  odontoblasts  which  cover  the  root  of  the  tooth.  This 
epithehum  proliferates  and  forms  a  gland-hke  structure  whose  lumen 
dilates  until  a  cyst  is  formed.  These  tumors  occur  between  the  ages 
of  sixteen  and  thirty-five,  especially  in  women.  They  are  more  fre- 
quent in  the  lower  jaw  than  in  the  upper,  in  the  proportion  of  one  to 
thirty. 

Their  growth  may  be  quite  rapid  and  they  cause  parchment-like 
crepitation,  also  called  egg-shell  crackhng,  as  they  develop.  They  can 
be  recognized  by  their  rapid  and  massive  growth,  the  parchment-Hke 
crackhng,  and  the  absence  of  tendency  to  ulceration  or  of  enlargement 
of  lymph-nodes. 

They  must  be  differentiated  from  dentigerous  cysts,  which  are  usually 
monocular  and  occur  at  an  earher  age.  The  jaw  also  does  not  attain 
the  size  of  cystadenomata.  The  same  is  true  for  the  softer  odontomata, 
the  harder  form  not  being  difficult  to  differentiate.  Sarcomata  occur 
at  a  younger  age,  do  not  grow  as  rapidly,  and,  unless  of  the  softer 
variety,  are  more  bone-like. 

Carcinoma  rarely  occurs  in  the  lower  jaw  and  appears  later  in  life 
than  either  cystadenomata,  odontomata,  or  dentigerous  cysts. 

Osteomata. — Osteomata  occur  most  frequently  in  the  lower  jaw, 
although  occasionally  an  osteoma  will  develop  into  the  antrum  of  High- 
more  and  give  rise  to  symptoms  of  pressure  upon  the  infraorbital  nen'e 
and  gradual  bulging  of  the  anterior  wall.  They  may  grow  also  toward 
the  orbital  cavity  or  toward  the  nose.  Both  in  the  upper  and  lower  jaws 
they  can  be  recognized  by  their  bony  consistency  and  their  slow  growth. 
Occasionally  osteomata  having  their  origin  in  the  wall  of  the  antrum  may 
be  recognized  by  the  .v-ray,  but  othenvise  the  same  may  be  said  of  this 
class  of  tumors  as  of  all  the  tumors  of  the  upper  jaw  which  originate  in 
the  antrum,  that  they  cannot  be  diagnosed  until  they  grow  beyond  the 
walls  and  cause  bulging  of  the  same.  One  can,  however,  suspect  their 
presence  from  the  complaint  of  dull  pain  over  the  antrum  and,  in  the 
case  of  sarcomata  or  carcinomata,  of  escape  of  blood  and  mucus  from 
the  nose,  without  the  ordinar}'  symptoms  of  an  empyema.  Osteomata 
of    the    lower   jaw    must    be    differentiated    from    ostcosarcomata.     If 


TUMORS.  Ill 


periosteal,  they  can  be  readily  recognized,  sometimes  growing  to  quite 
enormous  size.  Their  growth,  however,  is  exceedingly  slow,  and,  even 
though  they  be  central  in  origin,  they  rarely  cause  any  atrophy  of  the 
overlying  bone  such  as  will  give  rise  to  egg-shell  crackling. 

Granulomata  (granulation-tissue  tumors). — ^These  are  soft  masses 
of  granulation-tissue  which  project  beyond  the  level  of  the  gum  from 
the  sockets  in  which  carious  teeth  He.  They  are  oftenest  found  in 
children.  The  absence  of  an  increase  in  size,  their  soft  consistency, 
and  their  relation  to  a  carious  tooth  will  enable  a  differentiation  from  a 
fibroma  or  a  true  epuhs  to  be  made. 


Fig.  67. — Osteoma.     (International  Text-Book  of  Surgery.) 

Fibromata. — ^These  may  either  have  their  origin  in  the  periosteum 
or  in  the  central  portions  of  the  jaw.  The  former  are  more  frequent, 
only  eleven  cases  having  been  reported  of  the  latter.  Both  the  central 
and  periosteal  forms  occur  between  the  ages  of  sixteen  and  thirty-five. 
The  periosteal  can  be  recognized  clinically  as  a  small,  hard  tumor, 
growing  from  the  periosteum  of  the  outer  surface  of  the  jaw,  usually  of 
the  lower  jaw.  The  central  form  cannot  be  recognized  until  it  has 
grown  to  a  sufficient  size  to  have  caused  expansion  of  the  bone  overlying 
it.  They  occur  almost  exclusively  in  the  lower  jaw,  and  until  there  is  a 
prominence  over  the  bone  (Fig.  68)  the  patient  is  not  aware  of  its 


112 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


presence  unless  exceptionally  it  presses  upon  the  mental  nerve.     Parch- 
ment-like crackling,  so  frequently  observed  in  the  other  forms  of  tumors 


Fig.  68. — View  or  Lower  Jaw  in  a  Case  of  Central  Fibroma. 


\    .r^ 


of  the  jaw,  is  very  rarely  present,  only  once  in  eleven  cases.  As  a  rule, 
the  cortex  of  the  bone  is  intact.  The  chief  conditions  from  which  these 
tumors   must   be  differentiated  are  in  a  periosteal  fibromata,  from  a 

periosteal  sarcomata.  The  consis- 
tency of  the  latter  is  softer,  as  a  rule, 
and  the  growth  is  more  rapid  than  in 
the  case  of  a  fibroma.  The  central 
fibromata,  after  they  have  caused 
sufficient  expansion  of  the  bone  to 
be  recognized,  must  be  differentiated 
from  the  central  form  of  sarcomata. 
As  a  rule,  central  fibromata  do  not 
grow  as  rapidly  as  the  same  form  of 
sarcomata,  nor  do  they  give  rise  to 

Fig.  69.— Epulis  (Edmund  Owen).  egg-shcll     Crackling     SCnsatioUS,     Or 

break  through  the  shell  of  bone  in 
their  growth,  as  do  the  sarcomata.  The  periosteal  form  is  also  called 
false  or  fibrous  epuhs. 


TUMORS. 


"3 


There  is  a  rare  form  of  central  actinomycosis  which  may  resemble 
the  central  fibromata,  but  in  these  there  is  tendency  to  early  softening 
and  perforation  of  the  bone  with  sinus  formation,  and  the  discharge  of 
pus  containing  yellowish  granules  with  the  characteristic  organisms. 

Chondromata. — Chondromata  seldom  occur  in  the  jaws  as  pure 
cartilage  tumors.  They  are  most  frequently  present  in  the  form  of 
chondrosarcomata  or  osteochondromata,  which  are  allied  to  the  sar- 
comata clinically.  They  occur  as  central  chondromata  in  both  the 
upper  and  lower  jaws  and  as  periosteal  chondromata  in  both  jaws, 
but  especially  in  the  upper.  They  form  hard  nodular  tumors,  which  have 
the  characteristic  consistency 
of  cartilage.  The  sensation 
on  palpation  can  be  com- 
pared to  that  felt  on  pressure 
over  the  nasal  cartilages. 
Their  growth  varies  greatly, 
that  of  the  pure  chondromata 
being  very  slow,  so  that  the 
central  form  cannot  be  recog- 
nized until  it  breaks  through 
the  bone.  The  more  they  re- 
semble the  sarcomata  in  his- 
ologic  structure,  the  more 
rapidly  do  they  grow. 

Malignant   Tumors  of  the 
Jaws. 

Sarcomata. — Sarcoma  is 
the  most  frequent  form  of 
malignant  tumor  of  the  jaws. 

They  may  arise  from  the  gums  at  the  side  of  the  tooth,  giving  rise 
to  a  soft,  often  pedunculated  (Fig.  69)  tumor,  which  must  be  dif- 
ferentiated from  the  ordinary  fibrous  form  of  epulis.  In  the  case 
of  the  sarcomatous  epulis,  there  is  chnically  the  history  of  a  rather 
rapid  growth  and  expansion  of  the  surrounding  bone.  Histologically, 
these  tumors  show  distinctly  the  structures  of  a  mixed  giant-  and 
spindle-celled  sarcoma.  The  fibrous  form  of  epulis  is  much  firmer 
than  the  sarcomatous  in  consistency,  and  its  growth  is  much  slower. 
There  is  also  but  little  tendency  to  cause  expansion  of  the  bone.  Another 
variety  of  tumor  must  sometimes  be  differentiated.  This  is  not  a  true 
tumor,  but  simply  a  mass  of  granulation-tissue  which  may  arise  in  the 


Fig.  70. — Sarcoma  or  the  Antrum.     (International  Text- 
Book  of  Surgery.) 


114 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


cavity  from  which  either  a  tooth  has  been  extracted  or  in  which  a  carious 
tooth  Ues.  It  is  composed  of  flabby,  edematous  granulations,  and  has 
a  narrow  pedicle,  which  can  be  traced  up  into  the  cavity  occupied  by 
the  extracted  or  carious  tooth.  It  is  much  softer  than  the  sarcomatous 
epulis  and  can  be  readily  recognized  as  composed  of  granulation-tissue. 
It  can  be  differentiated  from  the  sarcomatous  epulis  by  the  fact  that 
the  latter  is  firmer  than  this  granuloma.  Both  the  granuloma  and 
sarcomatous  epulis  bleed  easily.  The  history  will  also  show  that  the 
sarcomatous  epulis  has  growTi  more  rapidly  than  the  granulation-tissue 

tumor,  spreading  over  several 
alveoh,  and  not  being  confined 
to  a  single  alveolus,  as  is  the 
case  in  a  granuloma. 

The  central  sarcomata  be- 
gin either  in  the  body  of  the 
lower  jaw  or  in  the  bone  sur- 
rounding the  antrum  of  High- 
more  in  the  upper  jaw. 

The  diagnosis  of  such  a 
sarcoma  of  the  upper  jaw  of 
the  endosteal  or  myelogenous 
type  can  only  be  made,  as  a 
rule,  when  the  growth  has 
caused  expansion  of  the  over- 
lying bone.  If  the  tendency 
of  the  growth  is  toward  the 
nose,  it  has  at  times  been 
treated  for  a  polyp.  Usually 
it  grows  toward  the  face, 
causes  a  prominence  of  the 
cheek,  pushes  the  eyeball  up, 
and,  if  toward  the  palate,  causes  a  bulging  in  the  latter  (Fig.  70). 

In  the  lower  jaw  these  endosteal  or  central  sarcomata  cannot  be 
recognized  until  the  bone  has  been  expanded  by  the  growing  tumor 
(Fig.  71).  All  types  of  sarcomata  may  occur,  but  most  frequently  one 
finds  the  osteosarcomata  (Fig!  72). 

The  diagnosis  of  these  forms  of  central  sarcomata  of  the  lower  jaw 
may  be  made  by  the  history  of  a  rapid  enlargement  and  the  local  exami- 
nation. In  the  latter  one  finds  an  enlargement  of  the  jaw,  which  is 
usually  marked  both  on  the  side  toward  the  mouth  and  that  toward  the 
cheek.     In  the  softer  varieties  there  is  distinct  egg-shell  crackhng.     In 


Fig.  71. — Typical  Enlargement  of  the   Face  Due 

TO  TtJMOR  OF  THE    LOWER  JaW  (SaRCOMA)  ,  EITHER 

OF  THE  Ramus  or  of  the  Body,  Close  to  the 
Junction  of  these  Two  Portions  of  the  Infe- 
rior Maxilla. 


TUMORS. 


Ii: 


the  harder  forms,  with  more  analogy  to  the  osteosarcomata,  the  growth 
is  quite  firm  and  bone-Hke. 

In  the  upper  jaw,  sarcomata  must  be  diiJerentiated  from  carcinomata 
arising  from  the  antrum  of  Highmore.  This  cannot  be  done  until  the 
tumor  has  gro^^^l  to  a  sufficient  size  to  be  palpated  through  the  mouth. 
In  the  case  of  osteosarcomata  or  chondrosarcomata,  palpation  shows 
them  to  be  much  firmer  than  a  carcinoma.  Carcinomata  tend  to  ulcer- 
ate upon  breaking  through 
the  walls  of  the  antrum  much 
earher  than  is  the  case  with 
sarcomata. 

In  regard  to  age,  carcino- 
mata appear  at  a  much  later 
period  of  Hfe  than  sarcomata. 
There  is  quite  early  involve- 
ment of  the  regional  lymph- 
nodes  (submaxillary  and  deep 
cervical)  in  a  carcinoma. 

Carcinoma  of  the  upper 
jaw,  as  a  rule,  grows  much 
more  rapidly,  and  is  more 
painful  than  is  the  case  in 
sarcomata  of  the  upper  jaw. 

From  fibromata,  both  of 
the  upper  and  lower  jaw,  sar- 
comata may  be  differentiated 
by  their  more  rapid  growth 
and  the  tendency  to  invade 
surrounding  structures.  The 
central  fibromata  of  the  lower 
jaw  are  quite  localized,  often 
encysted  tumors,  which  is  not  the  case  with  sarcomata.  From  the  other 
forms  of  benign  tumors  of  the  jaws,  like  chondroma  and  osteoma,  sar- 
comata may  be  readily  differentiated  by  their  rapid  growth.  It  must  be 
remembered  that  the  pure  form  of  chondroma  is  comparati^•cly  rare,  the 
majority  of  these  being  chondrosarcomata. 

Carcinoma  of  the  Jaws. — ^These  appear  (a)  either  as  primary 
tumors  of  the  gums  or  growths  arising  from  the  mucosa  of  the  antrum 
of  Highmore,  or  (b)  as  secondary  tumors  by  direct  extension  from 
neighboring  carcinomatous  involvement,  cither  of  the  mouth  or  of  the 
face  (Fig.  73).     The  diagnosis  of  carcinoma  arising  from  the  mucous 


Fig.  72. — Recurrent  Osteosarcoma  of  the  Superior 
Maxilla. 
This  illustration  shows  the  typical  site  of  tumors  of 
the  upper  jaw  which  protrude  externally,  showing  how 
they  involve  the  surrounding  osseous  and  soft  structures. 
The  curved  line  indicates  incision  of  first  operation. 


ii6 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


Fig.  73. — Primary   Carcinoma   of   Gums   of  Lower  Jaw, 
Well  Shown  by  Everting  Lower  Lip. 


membrane^of  the  antrum  can  only  be  made,  as  was  stated  above,  when 

the  tumor  is  of  sufficient 
size  to  grow  toward  the 
nose,  face,  or  palate. 
They  usually  appear  dur- 
ing the  later  years  of  life; 
their  growth  is  quite  rapid, 
much  more  so  than  is  the 
case  of  sarcoma  of  the 
upper  jaw,  and  there  is 
greater  tendency  to  ulcera- 
tion. The  most  frequent 
form  of  carcinoma,  how- 
ever, is  that  which  arises 
from  the  mucous  mem- 
brane of  the  gums  (Fig. 
73)  or  palate,  and  of  this 
variety  those  occurring  in 
the  upper  jaw  are  more 
frequent.  They  ahnost 
invariably  appear  in  elderly  people  in  the  form  of  a  carcinomatous 
ulcer  which  is  deeply  excavated  and  has  raised,  everted,  and  markedly 
indurated  edges.  There  is 
quite  early  enlargement  of 
the  submental,  submaxillary, 
and  deep  cervical  lymph-nodes 
(Fig.  74).  The  diagnosis  in 
the  earher  stages  is  not  diffi- 
cult when  one  considers  that 
all  other  forms  of  ulceration 
which  occur  at  this  period  of 
Hfe  are  not  accompanied  by 
enlarged  indurated  lymph- 
nodes.  Such  ulcerations  may 
occur  in  elderly  people  as  the 
result  of  sharp  teeth  or  of  an 
ulcerative  stomatitis,  as  the  re- 
sult of  improper  care  of  the 
mouth.     In  both  of  these  the 

ulcers      are      quite      superficial;  Fig.    74. -enormous     Secondary    Carcinomatous 

^  _  Lymph-nodes  of  Neck,  Following  Primary  Car- 

the   edges  are    seldom    indur-  cinoma  of  gums,  shown  in  fig.  73- 


INFECTIONS    OF   THE    JAWS.  II7 

ated,  and  the  ulceration   rapidly  disappears  as  soon  as  the  cause  is 
removed. 

From  tertiary  gummata  the  carcinomatous  ulcer  can  be  differen- 
tiated by  the  fact  that  gummata  seldom  occur  on  the  jaws  except  on  the 
palate.  There  is  usually  a  history  of  syphihs  or  the  presence  of  syphilis 
elsewhere.  No  enlargement  of  the  regional  lymph-nodes  occurs  and  the 
edges  are  never  as  indurated  as  is  the  case  in  a  carcinomatous  ulcer. 
The  administration  of  potassium  iodid  will  show  a  marked  improve- 
ment if  the  ulcer  is  a  gumma. 


INFECTIONS  OF  THE  JAWS. 

In  order  to  be  able  to  recognize  inflammatory  processes  of  the  jaws, 
it  is  necessary  to  have  a  clear  conception  of  their  pathology  as  well  as 
of  their  clinical  appearance. 

It  is  important  to  determine  (a)  the  nature  of  the  process  and  (b)  the 
extent  of  involvement  of  the  bone. 

The  nature  of  the  affection  varies  somewhat  according  to  the  cause. 
The  most  important  of  the  latter  are: 

1.  Infection  from  the  teeth. 

2.  Infection  following  compound  fractures. 

3.  Tuberculosis. 

4.  Syphihs. 

5.  Actinomycosis. 

6.  Phosphorus  necrosis. 

7.  Acute  pyogenic  osteomyelitis. 

The  extent  of  the  process  varies  according  to  the  cause.  In  the 
majority  of  cases  following  tooth  infection  there  is  a  suppurative  per- 
iostitis with  the  formation  of  subperiosteal  abscesses  and  resultant 
necrosis  of  the  underlying  bone.  Such  an  abscess  may  form  around  the 
root  of  the  tooth  (Fig.  75)  and  remain  confined  to  this  location  or  it 
may  extend  to  the  extra-alveolar  portion  of  the  bone.  Here  its  further 
course  varies.  In  the  upper  jaw  the  pus  may  (a)  burrow  toward  the 
antrum  of  Highmore  (Fig.  75),  or  (b)  penetrate  the  tissues  of  the  cheek 
and  perforate  externally,  or  (c)  it  forms  a  subperiosteal  abscess  which 
causes  a  swelling  at  the  line  of  reflection  of  the  gum  and  mucosa  of  the 
cheek. 

In  the  lower  jaw  the  anatomic  conditions  differ.  Here  infective 
processes  either  form  (a)  an  abscess  within  the  alveolus  itself  around 
the  root  of  the  tooth,  or  (b)  it  causes  a  marked  periostitis,  usually  on 
the  outer  aspect,  or  (c)  the  infection  progresses  to  the  floor  of  the  mouth 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


and  to  the  loose  cellular  tissue  of  the  neck  (Fig.  75)  and,  if  not  arrested, 
to  the  anterior  mediastinum. 

These  various  degrees  of  infection  may  result  in  necrosis  of  the  bony 
structure  of  a  single  alveolus  or  of  a  number  of  them.  In  the  lower 
jaw  the  above  referred  to  periostitis  of  the  outer  aspect  is  either  of  a 
plastic  nature  w^hich  undergoes  resolution  or  the  infection  causes  a 

subperiosteal  abscess 
with  necrosis  of  a  la- 
mella or  more  of  the 
cortex  of  the  bone. 

A  true  osteomyel- 
itis, /.  e.,  an  involve- 
ment of  the  medulla  of 
the  bone,  is  very  rare 
after  tooth  infection. 

In  compound  frac- 
tures, tuberculosis, 
syphilis,  actinomyco- 
sis, and  in  infection 
following  the  acute  ex- 
anthematous  diseases 
the  pathologic  changes 
differ  only  in  extent 
from  those  already  de- 
scribed. 

The  chief  diagnos- 
tic points  of  the  var- 
ious inflammatory  pro- 
cesses are  as  follows: 
Infection  from 
Teeth.  — Abscesses 
around  the  root  of  the 
teeth  cause  severe  pain 
referred  to  the  tooth, 
accompanied  by  tenderness  on  pressure,  redness,  and  swelling  of  the 
gum.  There  is  always  more  or  less  swelling  and  induration  of  the 
overlying  skin,  especially  in  the  upper  jaw,  often  causing  marked  edema 
of  the  lower  eyelid  and  upper  Hp.  If  the  infection  migrates  through  the 
root  canal  it  may  penetrate  the  alveolus  and  give  rise  to  an  abscess  be- 
neath the  gum  (gum-boil),  indicated  by  swelHng  and  fluctuation  here. 
If  the  underlying  bone  of  the  alve®lar  process  is  necrotic,  the  opening 


Fig.  75. — Sagittal  Section  of  Head  to  Show  Spread  of  Sup- 
puration FROM  Infected  Teeth;  and  also  Location  of  Retro- 
pharyngeal Abscesses. 

SA ,  Subperiosteal  abscess  of  upper  jaw  opening  toward  cheek  and 
mouth  in  direction  of  black  and  white  arrows,  respectively;  lA,  sub- 
periostea!  abscess  of  lower  jaw  opening  toward  submaxillary  region 
and  chin  in  direction  of  white  and  black  arrows,  respectively;  LA ,  infec- 
tion in  submaxillary  subcutaneous  tissue  as  a  result  of  abscesses  arising 
from  teeth  and  from  floor  of  mouth  (this  condition  is  also  called 
angina  Ludovici) ;  EA ,  infection  around  roots  of  bicuspid  and  molar 
teeth  spreading  toward  antrum  in  direction  of  arrow;  SA,  retro- 
pharyngeal abscesses. 


INFECTIONS    OF   THE    JAWS. 


119 


from  which  the  pus  escaped  either  spontaneously  or  by  incision  con- 
tinues to  discharge.  A  fine  probe  passed  through  the  opening  encounters 
denuded  dead  bone.  If  the  necrosis  invoh^s  a  number  of  adjacent 
alveolar  processes  there  is  more  or  less  retraction  of  the  gums,  with  con- 
stant discharge  of  pus.  Upon  inserting  a  probe  the  extent  of  the  necrosis 
can  be  readily  determined.  In  advanced  cases  the  entire  alveolus  may 
be  necrotic.  The  recognition  of  a  form  of  infection  which  occurs  with 
especial  frequency  in  the  lower  jaw  is  the  palpation  of  a  swelling  which 
is  usually  quite  hard  at  first  over  the  infected  tooth.  The  further  clinical 
history  is  Hke  that  described  above. 
In  children  spontaneous  perfora- 
tion through  the  cheek  over  both 
upper  and  lower  jaws  is  frequent. 
A  sinus  is  present  externally  along 
which  a  probe  can  be  passed  until 
exposed  bone  is  encountered  (Fig. 

75). 

In  connection  with  the  diag- 
nosis of  infection  of  the  upper  jaw 
from  carious  teeth  it  is  well  to  call 
attention  to  the  fact  that  an  em- 
pyema of  the  antrum  of  Highmore, 
especially  if  acute,  will  cause  irrita- 
tion of  the  nerves  of  the  bicuspids 
and  first  molar,  so  that  these 
teeth  are  often  thought  to  be  dis- 
eased. 

Infection  Following  Com- 
pound Fractures. — ^Necrosis  of 
the  jaw  is  present  in  these  cases 
when  (a)  a  sinus  is  present,  either 
within   the   mouth   or   externally, 

which  leads  to  denuded  bone  at  the  seat  of  fracture;  (b)  if  abscesses 
form  after  a  fracture  which  heal  and  then  fill  up  again  until  a  piece 
of  necrotic  bone  is  either  removed  by  operation  or  spontaneously  dis- 
charged. 

Tuberculosis  of  the  jaws  is  quite  rare.  It  is  most  frequently 
located  at  the  junction  of  the  superior  maxilla  and  malar  bone.  It 
causes  a  sweUing  along  the  lower  border  of  the  orbit  which  has  all  of 
the  clinical  characters  of  a  tuberculous  or  cold  abscess.  These  are  the 
gradual  appearance  of  a  swelhng  without  pain,  redness,  or  rise  of  local 


Fig.    76. — Suppuration    of   the   Submaxillary 
Lymph-nodes. 
Infection  of  the  surrounding  cellular  tissue  of 
this  region  and  of  the  cheek,  the  latter  almost  clos- 
ing the  eye,  followed  tooth  infection. 


I20  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

or  general  temperature.  The  skin  over  it  is  bluish  and,  after  evacuation 
J  of  the  pus  has  occurred,  a  sinus  persists  whose  edges  are  hned  by  flabby, 
often  caseous,  granulations. 

Tuberculosis  also  occurs  in  the  alveolar  and  palatal  processes  and 
in  the  body  of  the  lower  jaw.  The  diagnosis  in  these  locations  can  only 
be  made  by  excluding  the  other  forms  of  infection  and  the  peculiarly  slow 
onset. 

Tuberculosis  of  the  lower  jaw  may  resemble  sarcoma,  syphilis,  and 
actinomycosis.  A  sarcoma  of  the  body  of  the  lower  jaw  grows  more 
rapidly;  it  is  not  accompanied  by  necrosis  of  the  bone,  but  a  gradual 
thinning  of  the  same  (page  114). 

Syphihs  is  rare  in  the  lower  jaw  and  there  are  usually  evidences  of 
the  disease  elsewhere. 

Actinomycosis  is  not  apt  to  be  accompanied  by  swelhng  of  the 
lymph-nodes,  as  is  the  case  in  tuberculosis.  The  pus  contains  fine 
yellow  granules  in  which  the  ray  fungus  is  found. 

Syphilis. — In  the  lower  jaw  it  appears  as  a  periostitis  which  causes 
either  circumscribed  or  more  diffuse  swellings.  The  diagnosis  can 
only  be  made  if  other  causes  of  periostitis,  especially  those  due  to  tooth 
infection,  are  ex:cluded.  There  is  usually,  however,  a  history  of  syphilis 
elsewhere. 

The  hard  palate  is  the  most  frequent  locahzation  of  tertiary  syphilis 
in  the  jaws.  It  causes  a  painless  swelling  which  opens  spontaneously, 
exposing  denuded,  often  foul-smelling,  bone.  In  other  cases  the  patient 
may  present  himself  for  an  opinion  as  to  the  nature  of  a  perforation  of 
the  hard  palate  leading  into  the  nose. 

The  alveolar  processes  of  both  jaws  and  of  the  nasal  process  of  the 
upper  jaw  are  also  frequent  seats  of  syphihs,  especially  of  the  type 
known  as  the  late  hereditary,  which  first  appears  in  children  at  the  age 
of  puberty. 

A  diagnosis  of  the  latter  form  can  be  made  by  a  careful  history,  the 
absence  of  any  other  causes  of  necrosis,  and  antisyphihtic  treatment. 

Actinomycosis. — ^This  inflammatory  disease  of  the  lower  jaw 
occurs  far  more  frequently  than  was  formerly  thought.  It  is  almost 
invariably  secondary  to  a  primary  infection  of  the  gums  or  mucous 
membrane  of  the  cheeks,  which  is  rapidly  followed  by  infection  of  the 
soft  tissues  of  the  face  and  neck,  as  described  on  page  118. 

In  the  jaws  actinomycosis  may  either  appear  as  an  accompaniment 
of  the  same  affection  in  the  soft  parts  or  as  an  independent  clinical  entity. 
There  are  two  forms,  a  peripheral  and  a  central,  both  of  which  most 
frequently  involve  the  lower  jaw.     The  peripheral  form  of  jaw  actino- 


INFECTIONS    OF   THE    JAWS.  121 

mycosis  either  causes  a  superficial  necrosis  or  abscesses,  varying  in  size 
from  a  pea  to  a  hazelnut,  filled  with  soft  granulations.  In  the  pus 
from  these  latter  cavities  the  actinomyces  are  found.  These  abscesses 
may  first  arouse  the  suspicion  of  the  surgeon  or  dentist  on  account  of  the 
absence  of  acute  inflammatory  symptoms  and  the  fact  that  they  recur 
from  time  to  time. 

The  central  variety  of  actinomycosis  of  the  lower  jaw  occurs  in  two 
forms — (a)  a  penetrating  and  (b)  a  tumor-Hke  form.  In  the  former 
there  is  marked  rarefaction  without  the  formation  of  sequestra,  but 
considerable  thickening  of  the  outer  layer  of  bone.  This  form  is 
very  virulent,  especially  when  it  affects  the  upper  jaw.  The  tumor- 
like form  is  rarely  met  with  in  man,  occurring  usually  in  cattle  as  lumpy 
jaw.   Its  course  is  very  slow  and  results  in  the  formation  of  multiple  cysts. 

The  diagnosis  of  actinomycosis  of  the  jaws,  as  is  the  case  elsewhere, 
can  only  be  made  if  the  characteristic  organism  is  found.  It  bears 
great  resemblance  clinically  to  ordinary  tooth  infections,  especially 
if  associated  with  involvement  of  the  cellular  tissue  of  the  neck.  The 
course  of  actinomycosis  is  slower,  it  is  more  often  accompanied  by 
trismus  (see  page  122),  and  there  is  often  a  history  of  chewing  hay, 
grain,  etc.,  or  of  having  been  around  infected  cattle. 

Phosphorus  Necrosis. — Owing  to  the  regulation  of  the  manufac- 
ture of  matches,  this  disease  is  practically  extinct.  It  affects  the  lower 
jaw  more  often  than  the  upper.  The  chnical  picture  is  that  of  a  suppu- 
rative periostitis,  but  the  pus  is  very  foul  and  necrosis  is  more  extensive 
than  is  the  case  in  ordinary  tooth  infection. 

Acute  Suppurative  or  Pyogenic  Osteomyelitis. — ^This  affection 
usually  occurs  in  young  persons,  in  the  lower  jaw.  It  may  follow 
the  acute  exanthemata  like  measles,  scarlatina,  and  variola,  or  occur 
simultaneously  with  acute  osteomyeHtis  of  other  long  bones.  In  other 
cases  the-re  is  no  apparent  cause. 

The  diagnosis  presents  no  difficulties.  In  the  milder  type  the 
disease  more  frequently  involves  the  upper  jaw.  There  is  gradually 
swelhng  of  the  face  over  the  superior  maxilla  of  one  side  or  over  the 
entire  lower  jaw  with  moderate  fever.  This  is  followed  by  necrosis  of 
the  entire  alveolar  process  with  the  loss  of  the  temporary  teeth  as  well 
as  the  non-erupted  permanent  teeth. 

In  the  more  severe  form  the  course  is  much  more  like  that  of  the 
same  disease  in  the  extremities.  It  begins  with  a  chill,  followed  by 
high  fever  and  marked  increase  of  pulse-rate.  There  is  extensive 
swelhng  and  redness  of  the  soft  parts  over  the  jaw  and  severe  septic 
symptoms. 


122  SURGICAL    AFFECTIONS    OF   THE   HEAD. 

DISEASES  OF  THE  TEMPORO-MAXILLARY  JOINT. 

This  articulation  is  subject  to  the  same  forms  of  inflammation  as  is 
the  case  in  the  joints  of  the  extremities.     These  are: 

Primary  Acute  Arthritis: 

1.  Acute  traumatic  arthritis  (sprains). 

2.  Acute  articular  rheumatism. 
Secondary  Acute  Arthritis: 

1.  Metastatic,  .(a)  Through  infection  with  ordinar}^  pus  cocci 

by   metastasis   from   foci    elsewhere   in 
the  body. 
{h)  Through   infection  with   gonococci,   after 
scarlatina,  typhoid,  etc. 

2.  Direct Through    extension    into    the   joint    from 

neighboring  foci  of  suppuration. 
Chronic  Arthritis: 

1.  Tuberculosis. 

2.  Arthritis  deformans. 

Of  the  above,  the  acute  inflammations  are  most  often  a  result  of 
acute  articular  rheumatism  or  a  metastasis  from  a  gonorrheal  infection. 
The  diagnosis  is  not  difficult.  There  are  redness,  swelhng,  and  pain 
over  the  joint,  which  latter  is  just  in  front  of  the  tragus  of  the  ear. 

Pyemic  inflammation  is  also  not  rare.  The  chronic  forms  are 
characterized  by  pain  over  the  joint  upon  movements  of  the  jaw,  crepi- 
tation, and  slight  swelhng.  There  are  two  forms  of  chronic  inflammation 
of  the  joint  which  lead  to  relaxation  of  the  ligaments  and  favor  subluxa- 
tion. One  of  these  forms  is  the  result  of  an  arthritis  deformans  which 
usually  accompanies  the  same  disease  in  other  joints.  The  move- 
ments of  the  jaw  are  accompanied  by  pain  and  crepitation  and  are  very 
difficult. 

Ankylosis  of  the  Temporo-maxillary  Joint. — Trismus  (lockjaw) 
is  the  name  given  to  inability  to  open  the  mouth.  It  may  be  congenital 
and  acquired.  The  following  forms  exist  of  the  latter:  (a)  A  reflex 
spasm  of  the  masseter  muscles  following  acute  inflammatory  diseases 
of  the  jaws  and  occurring  most  frequently  during  the  eruption  of  the 
wisdom-teeth — it  has  been  given  the  name  '"symptomatic  lockjaw"; 
(h)  as  the  first  symptom  of  tetanus  (see  page  540);  (c)  as  a  result  of  acute 
or  chronic  disease  of  the  temporo-maxillar\'  joint;  {d)  as  a  result  of 
cicatrices  in  the  tissues  around  the  joint;  (e)  as  a  result  of  disease  of  the 
adjacent  bones,  especially  after   osteomyelitis   of  the   condyle   of  the 


STOMATITIS.  123 

lower  jaw  in  children.  It  is  very  apt  to  follow  acute  gonorrheal  arthri- 
tis and  those  varieties  of  suppurative  arthritis  which  are  due  to  metastasis 
or  to  direct  extension  from  neighboring  foci  in  the  ear,  mastoid,  etc. 

The  diagnosis  of  the  existence  of  an  ankylosis  is  much  easier  than 
that  of  its  cause.  The  cause  of  an  acquired  ankylosis  can  be  ascertained 
through  a  careful  history,  an  examination  of  the  rest  of  the  body  and  of 
the  structures  around  the  joint.  A  congenital  ankylosis  is  frequently 
accompanied,  or  rather  followed,  by  a  lack  of  development  of  the  lower 
jaw.^ 

Diseases  of  the  Mouth. 

Injuries. — -Injuries  of  the  lips  and  buccal  cavity  present  no  diffi- 
culties in  diagnosis.  It  is  of  interest  to  note  that  wounds  of  the  mouth 
are  covered  with  a  grayish-white  deposit  within  twenty-four  hours, 
which  to  those  unaccustomed  to  see  it  causes  them  to  think  it  at  first 
sight  to  be  the  pseudo-membrane  of  diphtheria. 

STOMATITIS. 

There  are  two  principal  forms  of  inflammation  of  the  buccal  mucosa, 
viz.,  an  ulcerative  or  catarrhal  and  gangrenous.  In  gangrenous  stoma- 
titis or  noma  there  is  a  history  of  some  recent  infectious  disease,  such  as 
measles,  or  the  patient  is  quite  cachectic.  In  its  earhest  stages  there 
is  a  blister,  usually  on  the  inner  side  of  the  cheek,  which  soon  becomes 
gangrenous.  The  area  begins  to  spread  along  the  mucosa  and  in  the 
depth  of  the  cheek,  so  that  it  penetrates  the  cheek.  The  gangrene  is 
accompanied  by  a  markedly  fetid  breath  and  the  symptoms  of  general 
sepsis. 

Ulcerative  stomatitis  is  characterized  by  greatly  swollen,  reddened, 
readily  bleeding  gums,  accompanied  by  salivation.  Particles  of  food 
and  detritus  collect  at  the  junction  of  the  gums  and  teeth,  and  there  is 
great  fetor.  Ulcers  often  appear  on  the  inner  side  of  the  lips  and  cheeks 
and  along  the  borders  of  the  tongue.  They  are  flat  and  could  only  be 
confused  with  mucous  patches  of  secondary  syphilis.  The  latter  are, 
however,  not  accompanied  by  fetor,  swollen  bleeding  gums,  and  sali- 
vation unless  there  is  an  accompanying  mercurial  stomatitis.  Even  then 
the  distinction  can  be  made  by  an  examination  of  the  remainder  of  the 
body  for  other  evidences  of  syphihs,  and  the  fact  that  the  mucous  patches 
are  seldom  ulcerated,  are  fewer  in  number,  and  seldom  occur  on  the  gums 
or  inner  side  of  the  cheeks,  but  most  often  on  the  edges  of  the  tongue. 

'  Orlow:  "Deutsche  Zeitschrift  fiir  Chirurgie,"  Bd.  60. 


124 


SURGICAL    AFFECTIONS    OF   THE   HEAD. 


In  scurvy  the  gums  are  swollen  and  bleed  readily,  and  there  are 
apt  to  be  subperiosteal  hemorrhages  causing  tenderness  over  the  long 
bones  and  hemorrhages  into  the  joints  causing  swelling  of  the  latter. 


SYPHILIS. 

Tertiary  syphihs  in  the  form  of  ulcerating  gummata  occasionally 
affects  the  inner  side  of  the  cheek  and  may  cause  perforation.  The 
favorite  seat  of  perforations,  however,  is  at  the  junction  of  the  hard 

and  soft  palates,  where  it 
causes  deep  ulceration  and 
perforation  of  the  palate. 
Tertiary  syphilis  can  be 
distinguished  from  car- 
cinoma by  the  absence 
of  enlarged  lymph-nodes 
and  the  lack  of  induration 
in  syphilis  and  the  pres- 
ence of  evidences  of  the  dis- 
ease in  its  tertiary  form  else- 
where. 


Fig. 


77- 


-LocATiON  OF  Various  Cysts  in  Relation  to 
Tongue  and  Floor  of  Mouth. 
R,  Ranula;  Deep  D.  or  Thy.  C.  or  L.  G.,  location  of  deep 
dermoids,  of  thyroglossal  cysts  and  of  lingual  goiter  at  base  of 
tongue;  Sup.  D.,  location  of  superficial  dermoids  at  floor  of 
mouth  causing  bulging  of  submental  region;  T,  dorsum  of 
tongue;  Hy,  hyoid  bone;  E  epiglottis. 


THE  DIAGNOSIS  OF  CONDI- 
TIONS  AT   THE    FLOOR 
OF  THE  MOUTH. 

A   differential   diagnosis 

must  at  times  be  made  of 

conditions   which   occur    at 


the  floor  of  the  mouth.     These  are  (Fig.  77): 

1.  Inflammatory  conditions: 

(a)  Angina  Ludovici. 

(b)  Salivary  calculus. 

(c)  Acute  ranula. 

2.  Tumors: 

(a)  Of  the  submaxillary  sahvary  gland. 

(b)  Chronic  ranula. 

(c)  Dermoids. 

(d)  Thyroglossal  cysts. 

(e)  Carcinoma  of  the  floor  of  the  mouth. 
(/)  Lipoma. 

Angina  Ludovici. — ^This  occurs  either  as  a  compHcation  of  scar- 


THE  DIAGNOSIS  OF  CONDITIONS  AT  THE  FLOOR  OF  THE  MOUTH.     1 25 


latina  or  of  a  tooth  or  tongue  infection.  It  causes  a  tense  brawny 
infiltration  of  the  floor  of  the  mouth,  pushing  the  tongue  upward  and 
causing  difficuky  in  swallowing,  in  speech,  and  in  breathing.  It  is 
accompanied  by  the  evidences  of  severe  systemic  infection  (fever, 
leukocytosis,  etc.)  and  the  skin  of  the  neck  soon  becomes  infiltrated  and 
of  a  dark  red  hue. 

Salivary  Calculus. — ^This  may  occur  without  inflammatory  reac- 
tion   or    ulceration   and   is 

easy  to  feel  when  the  finger  "IIB 

is  pressed  along  the  floor  of 
the  mouth  or  a  probe  is 
passed  along  Wharton's 
duct.  If  the  calculus  be  sur- 
rounded by  connective  tis- 
sue, it  may  be  quite  hard 
and  resemble  a  carcinoma, 
especially  if  the  tissues 
around  the  calculus  be  ul- 
cerated and  the  ulcer  be  sur- 
rounded by  exuberent  gran- 
ulations. A  differential 
diagnosis  can  usually  be 
made  by  the  use  of  a  probe 
passed  through  the  buccal 
opening  of  Wharton's  duct, 
on  either  side  of  the  frenum 
of  the  tongue  close  to  the 
floor  of  the  mouth,  and  en- 
countering the  calculus. 

Acute  Ranula. — ^The 
patient  gives  the  character- 
istic history  of  recurrent 
swellings  which  appear  very 

suddenly,  especially  while  eating.-  The  swelling  is  usually  most  marked 
just  below  the  angle  of  the  jaw  and  pushes  up  the  floor  of  the  mouth. 
It  may  attain  the  size  of  a  fist  and  subside  as  rapidly  as  it  appeared. 
It  is  due  to  the  occlusion  of  Wharton's  or  the  sublingual  ducts,  so  that 
the  saliva  collects  within  the  glands.  The  history  is  sufficiently  typical 
to  make  a  diagnosis  even  during  the  interval. 

Solid  Tumors  of  the  Submaxillary  Salivary  Gland. — ^These  are 
either  chondromata  or  cndothcliomata.     They  protrude  below  the  jaw 


Fig.  78. — Ranula. 

Note  the  prominent  tumor  on  right  side  of  floor  of  the  mouth, 

pushing  the  tongue  upward. 


126  SURGICAL   AFFECTIONS    OF    THE   HEAD. 

(Fig.  1 1 6)  and  bulge  in  the  floor  of  the  mouth.  A  diagnosis  can  be 
readily  made  by  the  firm  consistency  of  the  tumor  and  the  fact  that  its 
major  portion  Hes  in  the  normal  position  of  the  submaxillary  sahvary 
gland  on  the  inner  side  of  the  jaw,  close  to  the  angle. 

Chronic  or  Ordinary  Ranula. — As  a  rule,  this  tumor  is  unilateral 
(Fig.  78).  It  pushes  the  tongue  upward  and  appears  as  a  translucent 
tumor  varying  in  size  from  a  pea  to  an  egg  in  the  floor  of  the  mouth. 
It  has  its  origin  in  the  cystic  dilatation  of  the  subKngual  gland  and  is  a 
retention-cyst.     Its  fluid  contents  are  like  the  white  of  an  egg. 

It  can  be  differentiated  from  a  hpoma  of  the  floor  of  the  mouth  by 
the  yellowish  color,  the  lobulated  structure,  and  firmer  consistency  of 
the  lipoma. 

From  a  dermoid  of  the  sublingual  variety  (Fig.  77)  it  can  be  distin- 
guished by  the  fact  that  a  dermoid  is  doughy,  is  not  translucent,  has 
thicker  walls,  is  attached  to  the  lower  jaw  or  hyoid,  and  Hes  deeper. 
A  cystic  dilatation  of  Wharton's  duct  or  chronic  ranula  causes  a  cylin- 
dric  translucent  swelling  and  is  accompanied  by  some  enlargement  of 
the  submaxillary  sahvary  gland. 

Dermoid  Cysts. — ^These  occur  at  the  floor  of  the  mouth  and  have 
as  their  chief  characteristic  a  doughy  consistency,  so  that  they  pit  on  pres- 
sure. They  are  of  a  yellowish  color,  are  softer  than  a  calculus,  and  occur 
between  the  fifteenth  and  twenty-fifth  year.  They  are  situated  deeper 
than  a  ranula  (Fig.  77)  and  cause  more  bulging  of  the  submental  region. 

Thyroglossal  Cysts. — ^These  are  softer  than  dermoid  cysts  and 
push  the  tongue  up  and  back,  causing  difficulty  in  speech,  in  swallowing, 
and  in  breathing.  They  appear  externally  between  the  hyoid  and  the 
lower  jaw  in  the  median  line.  Their  deeper  situation,  absence  of 
translucency,  and  the  fact  that  they  occur  in  the  median  line  serves  to 
distinguish  them  from  a  ranula. 

Carcinoma  of  the  Floor  of  the  Mouth.— This  condition  may 
occur  as  a  primary  one  and  be  situated  in  a  fold  of  mucous  membrane, 
so  that  attention  is  only  called  to  its  presence  by  pain.  Upon  lifting 
the  tongue  up,  or  pushing  it  to  one  side,,  one  can  detect  an  ulceration 
with  dirty  floor  and  indurated  base  and  edges.  The  only  condition 
hkely  to  be  confounded  with  it  is  a  gumma.  In  the  latter  there  are  no 
enlarged  submental  or  submaxillary  lymph-nodes,  the  induration  is 
less  marked,  and  there  is  either  the  history  of  or  presence  of  syphihs 
elsewhere.  Carcinoma  of  the  floor  of  the  mouth  due  to  extension 
from  the  tongue  or  gums  presents  no  diagnostic  difficulties. 

Lipoma  at  the  floor  of  the  mouth  is  very  rare. 


THE    TONGUE.  I 27 

TUMORS  OF  THE  INSIDE  OF  THE  CHEEKS. 

The  most  frequent  forms  of  neoplasms  in  this  situation  are  the 
vascular  tumors  and  carcinoma.  The  former  have  been  referred  to 
previously  (see  page  98)  as  invading  at  times  the  entire  thickness  of 
the  cheek,  so  that  they  present  the  typical  picture  on  the  inner  side. 

An  angioma  may  be  primary  in  the  buccal  cavity,  i.  e.,  on  the  inner 
side  of  the  cheek,  on  the  tongue  or  fauces. 

The  hemangiomata  are  usually  of  the  venous  type,  so  that  one  can 
see  the  typical  soft  bluish  swelling  disappear  on  pressure. 

The  lymphangiomata,  if  present,  form  a  large,  soft  tumor  of  the 
entire  cheek,  congenital  in  origin,  and  growing  at  times  to  an  enormous 
size. 

Carcinoma  of  the  inner  side  of  the  cheek  is  usually  an  extension 
from  the  jaws  or  hps.  Only  twelve  cases  of  primary  carcinoma  of  the 
cheek  have  been  recorded.  They  occur  close  to  the  lower  jaw  and 
may  penetrate  the  cheek.  Their  induration,  raised,  everted,  hard  edges, 
and  tendency  to  early  ulceration,  with  enlargement  of  the  regional 
lymph-nodes,  are  so  characteristic  that  the  diagnosis  is  not  difficult. 

TUMORS  OF  THE  PALATE. 

The  majority  of  these,  if  primary,  are  fibromata,  and  can  be  readily 
diagnosed  from  their  position  and  consistency.  They  usually  arise 
laterally  and  grow  toward  the  median  line.  They  are  covered  by 
periosteum  and  are  slow  in  growth.  They  cause  difficulty  in  swallowing 
and  speech  and  must  be  distinguished  from  tumors  of  the  upper  jaw 
and  from  naso-pharyngeal  polyps,  which  have  grown  toward  the  antrum. 
In  the  case  of  tumors  of  the  jaw  we  have  usually  to  deal  with  mahgnant 
growths  which  increase  in  size  rapidly  and  also  cause  bulging  of  the 
anterior  surface  of  the  superior  maxilla.  In  the  case  of  naso-pharyn- 
geal polyps  an  examination  of  the  naso-pharynx  will  show  the  origin 
of  the  primary  tumor.  In  addition,  by  palpation  one  can  feel  that 
there  is  a  connection  between  the  palatal  vault  and  the  pharyngeal 
tumor  (Fig.  79). 

THE  TONGUE. 
Congenital  Affections. — The  most  important  congenital  affection 
is  the  ordinary  tongue-tie,  which  is  due  to  an  abnormal  shortness  of  the 
frenum  linguee.     This  can  be  recognized  in  infancy  by  inability  to  pro- 
trude the  tongue  as  far  forward  as  normal.     The  organ  can  seldom  be 


128 


SURGICAL    AFFECTIONS    OF   THE    HEAD. 


protruded  further  than  the  teeth.  The  condition  may  interfere  with 
nursing  and  later  with  speech.  The  tongue  is  bound  doAMi  to  the  floor 
of  the  mouth  and  the  shortened  frenum  can  be  easily  demonstrated  by 
lifting  the  tongue  up  with  a  grooved  director. 

Injuries  of  the  Tongue. — ^The  most  frequent  injuries  of  the  tongue 
are  punctured  or  lacerated  wounds.  These  are  either  due  to  foreign 
bodies,  which  penetrate  the  tongue  during  eating,  or  the  wounds  are 
received  during  a  fah,  the  tongue  being  caught  between  the  upper  and 
lower  teeth.  At  times  the  wounds  are  so  extensive  as  to  almost  com- 
pletely sever  the  tip  of 
the  tongue.  Foreign 
bodies  may  be  re- 
tained in  the  tongue 
and  cause  a  circum- 
scribed abscess,  which 
can  be  recognized  by  a 
swelling  which  is  usu- 
ally unilateral,  by  ten- 
derness, and  by  a  sense 
of  fluctuation. 

Dental  or  Decu- 
bital Ulcers, — ^These 
may  follow  the  con- 
stant irritation  of  a 
sharp  tooth  and  cause 
severe  pain.  Such  den- 
tal ulcers  are  usually 
situated  opposite  the 
canine  teeth,  at  the 
edges  of  the  tongue, 
and  cause  consider- 
able pain.  The  diag- 
nosis can  be  made  by  finding  the  source  of  irritation  and  the  fact  that 
the  ulcer  heals  rapidly  when  its  cause  is  corrected.  The  differentiation 
of  these  decubital  ulcers  of  the  tongue  from  carcinomatous  and  syphihtic 
ulcers  will  be  referred  to  again  (see  page  135). 

Acute  Parenchymatous  Glossitis.— This  may  follow  wounds  of  the 
tongue  or  may  occur  as  a  comphcation  of  the  acute  infectious  diseases. 
This  condition  occasionally  results  in  an  abscess  of  the  tongue  or  may 
be  the  starting-point  of  an  infection  of  the  cellular  tissue  of  the  floor  of 
the  mouth  and  neck  called  angina  Ludovici. 


Fig.  79. — Various  Locations  of  Pharyngeal  and  Esophageal 
Tumors. 
U,  Upper  jaw,  L,  lower  jaw,  Hy,  hyoid  bone;  E,  epiglottis;  i, 
naso-pharyngeal  growths;  the  arrows  point  in  the  direction  of  their 
most  frequent  extension  toward  the  nose  and  pterygo-maxillary  fossa 
and  downward  toward  the  mouth;  2,  location  of  retropharjTigeal 
growths;  3,  location  of  carcinomata  at  the  junction  of  anterior  wall  of 
pharynx  and  beginning  of  esophagus. 


THE   TONGUE, 


129 


Acute  glossitis  can  be  recognized  by  the  enormous  swelling  of  the 
tongue,  which  causes  obstruction  to  breathing,  with  resultant  dyspnea. 
The  tongue  cannot  be  moved,  feels  very  firm  and  board-Hke,  and  there 
is  profuse  saHvation  and  severe  pain.  The  temperature  as  a  rule  is  not 
high.  Swallowing  and  the  taking  of  nourishment  is  greatly  interfered 
with.  The  mouth  is  usually  held  open  and  the  entire  clinical  picture 
is  that  of  great  anxiety.  On  account  of  the  inabihty  to  move  the  tongue 
there  is  also  great  danger  of 
aspiration  pneumonia.  This 
condition  of  acute  glossitis  lasts 
from  three  to  five  days  and  may 
be  complicated  by  an  acute 
edema  of  the  glottis.  This 
complication  can  be  diagnosed 
by  the  marked  increase  in  dysp- 
nea, cyanosis,  and  the  stridor 
accompanying  the  inspiratory 
efforts.  The  only  condition 
with  which  acute  glossitis  can 
be  confused  is  an  acute  edema 
of  the  floor  of  the  mouth  due 
to  inflammation  around  a  sali- 
vary calculus.  This  latter  con- 
dition is  more  localized  and 
seldom  extends  to  the  tongue. 
It  is  always  present  on  the  floor 
of  the  mouth  and  by  palpation 
one  can  usually  demonstrate 
the  presence  of  the  calculus 
lying  in  Wharton's  duct. 

Leukoma  (leukoplakia , 
chronic  glossitis  or  psoriasis 
linguae). — This  is  a  condition 

which  is  very  frequent  in  smokers  and  is  present  on  the  inner  side  of 
the  cheeks  and  hps,  as  wefl  as  upon  the  tongue.  On  the  latter  it  pre- 
sents itself  in  the  form  of  milk-white  patches  of  varying  size.  These 
patches  of  leukoplakia  are  distinctly  white  in  color,  especially  on  the 
dorsum  (Fig.  80).  On  the  edges  and  under  surface  of  the  tongue  they 
have  a  httle  more  bluish  tint  and  are  translucent.  The  disease  may 
be  so  extensive  as  to  cover  the  entire  dorsum  of  the  tongue. 

The  chief  condition  from  which  it  must  be  differentiated  is  the 
9 


Fig.  80. — Psoriasis  Lingu.i;  (Hutchinson). 
Notice  the  silvery-white  area  characteristic  of  this  disease. 


130  SURGICAL    AFFECTIOXS    OF    THE    HEAD. 

mucous  patch  occurring  in  secondan,'  syphilis.  The  mucous  patch  is  of 
a  pure  white  or  yellowish- white  color  and  more  opaque  than  the  leukom- 
atous  or  smokers'  patches.  There  is  a  greater  tendency  on  the  part 
of  the  mucous  patches  to  extend  and  there  is  usually  evidence  of  syphihs 
elsewhere,  such  as  a  secondary  eruption  on  the  body  or  mucous  patches 
at  the  angle  of  the  mouth  or  on  the  tonsils.  Whitish  patches  not  infre- 
quently appear  on  the  edges  of  the  tongue  in  patients  who  have  had 
syphihs,  which  cannot  be  differentiated  from  ordinan,^  ,  leukoplakia, 
except  from  the  histon,"  of  a  previous  syphihs  and  their  greater  tendency 
to  ulcerate. 

Secondary  mucous  patches  are  most  often  found  on  the  edge  of  the 
tongue,  while  leukoplakia  appears  usually  on  the  dorsum  of  the  tongue. 
In  leukoplakia  there  is  no  enlargement  of  the  submaxillar}^  lymph-nodes, 
whereas  the  mucous  patches  are  often  accompanied  by  this  condition. 

Tuberculosis  of  the  Tongue. — This  is  usually  present  as  a  condi- 
tion secondary  to  tuberculosis  of  the  lar}-nx,  tonsils  or  lungs,  and  is 
oftenest  found  near  the  tip  of  the  tongue.  The  ulcer  is  of  a  grayish-pink 
color,  the  floor  is  covered  with  a  caseous  material,  and  the  edges  are 
undermined  and  not  indurated. 

Tubercular  ulcers  are  usually  quite  painful.  They  can  be  differ- 
entiated from  syphiHtic  ulcers  by  the  fact  that  the  latter  have  indurated 
edges  and  there  is  considerable  induration  of  the  tissues  around  them. 
The  ulceration  is  deeper  and  the  edges  are  not  undermined.  There  are 
no  enlarged  lymph-nodes  and  there  is  usually  the  presence  or  the  history 
of  syphihs  elsewhere.  Syphihs  affects  the  middle,  while  tuberculosis  is 
more  often  found  on  the  lateral  portions  of  the  tongue.  SyphiHtic  ulcers 
'are  painless. 

Tuberculosis  of  the  tongue  can  be  differentiated  from  carcinoma 
of  the  tongue  of  the  ulcerative  type  by  the  facts  (a)  that  the  induration 
in  carcinoma  is  verj^  marked;  (b)  that  the  ulcer  itself  is  not  painful  in 
the  early  stages;  (c)  that  there  are  no  evidences  of  tuberculosis  in  the 
lungs  or  elsewhere,  and  (d)  the  carcinomatous  condition  is  accompanied 
by  early  enlargement  of  the  submaxillary  or  deep  cervical  lymph-nodes. 
The  age  also  will  assist  in  the  diagnosis,  carcinoma  occurring  as  a 
general  rule  at  a  later  age  than  the  average  case  of  tuberculosis. 

Syphilis  of  the  Tongue. — This  may  appear  (a)  in  the  form  of  a 
primary  chancre;  (b)  in  the  form  of  secondar}'  mucous  patches,  which 
may  or  may  not  have  broken  down  to  form  ulcers;  (c)  in  the  form  of 
gummata,  which  may  be  superficial  or  deep,  and  (d)  as  a  syphilitic 
atrophy  of  the  base  of  the  tongue. 

Chancre  of  the  tongue  is  a  comparatively  rare  lesion.     It  is  usually 


THE   TONGUE. 


131 


present  on  the  upper  surface  or  anterior  edge.  It  shows  a  sHght  central 
depression,  with  its  floor  covered  with  necrotic  tissue,  and  has  moder- 
ately indurated  edges.  There  is  usually  quite  early  enlargement  of  the 
submaxillary  lymph-nodes  (Fig.  81).  The  diagnosis  can  be  confirmed 
within  a  comparatively  brief  period  by  the  appearance  of  secondary 
symptoms.  The  principal  condition  which  must  be  differentiated  from  a 
primary  syphihtic  lesion  of  the  tongue  is  a  decubital  or  dental  ulcer, 
which  may  also  be  present  along  the  edges  of  the  tongue.  This  dental 
ulcer  is  not  accompanied  by  any  enlargement  of  the  lymph-nodes,  and 
one  can  usually  find  the  source  of  the  ulcer  in  the  form  of  a  sharp  tooth 
and  the  ulcer  heals  as 
quickly  as  the  source  of 
irritation  is  removed. 

Secondary  syphil- 
itic lesions  or  mucous 
patches  occur  on  the 
borders  under  surface 
of  the  tongue.  They 
may  occur  simply  as 
pure  white,  small, 
slightly  raised  areas, 
which  are  quite 
opaque,  or  as  minute 
ulcers.  They  are  usu- 
ally quite  painful  and 
often  fissured.  A  con- 
dition from  which  they 
must  be  differentiated 
is  the  small,  painful, 
so-called  aphtha  some- 
times associated  with 

disturbances  of  digestion.  These  aphthous  patches  are  usually  oval  in 
outline,  seldom  multiple,  as  is  the  case  with  mucous  patches,  and  much 
more  painful.  The  absence  of  the  history  of  syphilis  and  of  evidences 
of  the  disease  elsewhere,  as  well  as  the  fact  that  the  condition  heals 
within  a  few  days  after  regulation  of  the  diet,  will  serve  to  exclude  this 
condition. 

Tertiary  Syphilitic  Lesions  0}  the  Tongue. — These  occur  about  five 
to  fifteen  years  after  the  primary  infection  and  are  usually  multiple.  They 
may  occur  as  gummatous  infiltrations  seated  deeply  in  the  substance  of 
the  tongue,  which  ulcerate  later,  or  as  superficial  gummata.     They  are 


Fig.  81. — Chancre  of  Left  Edge  of  Tongue,  with  Secondary 
Enlargement  of  Submaxillary  Lymph-nodes,  to  which 
THE  White  Arrow  Points. 


132 


SURGICAL   AFFECTIONS    OF   THE   HEAD. 


Fig.  82. — CAKCiNOiiA  of  Meddle  of    Left   Edge    of   Tongue 
Developing  upon  a  GuiiMA.    Anterior  vievi. 


most  frequently  pres- 
ent on  the  dorsum  of 
the  tongue,  but  may 
also  develop,  rarely, 
along  the  edge  of  the 
tongue.  An  ulcer, 
due  to  a  broken-down 
gumma,  has  only  a 
moderate  amount  of 
induration.  The  edges 
are  not  much  above 
the  level  of  the  sur- 
rounding tissue  and 
the  floor  of  the  ulcer  is 
necrotic.  The  edges 
are  not  everted,  Kke 
those  of  an  epitheh- 
oma,  and  are  quite 
steep  or  straight. 
There  is  no  enlarge- 
m.ent  of  the  regional  lymph-nodes,  viz.,  the  submental,  submaxillary, 
and  deep  cervical. 

The  differentiation 
from  a  dental  or  de- 
cubital ulcer  can  be 
readily  made  by  ascer- 
taining the  source  of 
irritation  and  by  the 
fact  that  the  indura- 
tion in  decubital  ulcer 
is  seldom  as  well 
marked  as  in  either  a 
syphihtic  or  a  carcin- 
omatous ulcer. 

In  case  of  any 
doubt,  the  removal  of 
the  cause  of  the  irrita- 
tion and  the  adminis- 
tration of  iodid  of  po- 
tassium for  a  period 
of  one  week  will  clear 
up  the  diagnosis. 


Fig.  83. — Lateral  View  of  a  Carcinoma  of   the  Left  Edge  of 

THE  Tongue. 

Same  patient  as  shown  in  Fig.  82. 


NOX-MALIGNANT    TUMORS    OF   THE    TONGUE.  1 33 

In  addition  to  this  therapeutic  test,  one  can  usually  obtain  a  history 
of  or  evidences  of  syphihs  elsewhere. 

TertisLTy  syphihs  may  occur  in  the  form  of  fissures  at  the  edges  of 
the  tongue,  which  are  quite  painful,  and  can  only  be  discovered  by 
separating  the  furred  epithehum  of  the  tongue.  Syphihs  is  the  most 
frequent  cause  of  fissures  of  the  tongue.  In  advanced  cases  these 
fissures  may  be  long  and  sinuous  and  resemble  either  a  tubercular  or 
carcinomatous  ulcer.  A  carcinoma  appearing  in  the  form  of  a  fissure 
has  markedly  indurated  edges  and  there  is  always  accompanying  en- 
largement of  the  submaxillary  and  deep  cendcal  lymph-nodes.  Car- 
cinoma may,  however,  develop  upon  a  tertiary  syphihtic  lesion  (Figs.  82 
and  83)  and  under  these  circumstances  a  differentiation  between  the 
two  at  an  early  stage  can  only  be  made  by  considering  the  degree  of 
induration,  w^hich  is  far  greater  in  carcinoma  than  in  syphihs,  and 
finding  enlarged,  hard  hmiph-nodes  under  the  chin  and  at  the  angle  of 
the  jaw. 

The  fourth  form  of  syphihs  of  the  tongue  is  the  so-called  syphihtic 
atrophy,  which  was  first  described  by  Virchow.  This  is  always  at  the 
base  of  the  tongue  and  shows  itself  by  a  smooth,  shining  condition,  due 
to  a  loss  of  the  epithehum  of  this  portion  of  the  tongue.  It  may  appear 
and  disappear  during  the  course  of  syphihs  from  time  to  time  or  may 
persist.  It  may  be  necessary  in  some  cases  to  differentiate  the  deep 
form  of  gummata  from  neoplasms  of  the  tongue,  such  as  carcinoma  or 
sarcoma.  Both  of  these  are  much  firmer  and  more  sharply  demarcated 
from  the  surrounding  structures  of  the  tongue,  the  gumma  is  inelastic, 
and  cannot  be  separated  from  the  surrounding  structures.  The  gum- 
mata often  occur  multiple,  while  carcinoma  and  benign  tumors  are 
almost  always  single. 

The  differentiation  of  tertiary  syphihtic  lesions  from  carcinoma 
will  be  referred  to  later. 


NON-MALIGNANT  TUMORS  OF  THE  TONGUE. 

These  arc  lipoma,  hemangioma,  lymphangioma,  and  papilloma. 
The  lipoma  occurs  late  in  hfe,  near  the  tip  or  on  the  dorsum  of  the 
tongue.  It  is  very  slow  in  growth,  and  can  readily  be  recognized  by  the 
fact  that  the  mucosa  is  stretched  over  the  tumor,  and  through  it  one  can 
see  the  lemon-yellow  fat.     There  is  also  distinct  lobulation. 

Hemangiomata  may  occur  in  the  capillary  form  as  deep  red 
nodules,  the  size  of  a  pea,  either  single  or  multiple,  on  the  dorsum  or 
edges  of  the  tongue.     They  present  the  same  characteristics  as  this 


134  SURGICAL   AFFECTIOXS    OF   THE   HEAD. 

form  of  tumor  elsewhere,  namely,  that  the  tumor  itself  can  be  caused  to 
disappear  by  pressure  but  speedily  returns  as  soon  as  it  is  relieved. 

The  other  form  of  hemangioma,  which  occurs  on  the  tongue,  is  the 
soft  palate  and  cheek.  It  may  involve  only  a  small  area,  or  an  entire 
half  of  the  tongue,  causing  considerable  swelKng,  which  can  be  greatly 
decreased  by  pressure  but  rapidly  refills. 

Lymphangioma. — Lymphangioma  may  occur  in  the  capillar}^  or 
cavernous  fonns  (Figs.  84  and  85).  The  former  can  be  recognized  by 
the  minute  vesicles  or  rarely  larger  cysts  which  are  present  along  the 
edges  and  dorsum  of  the  tongue.  The  vesicles  are  translucent  and 
about  the  size  of  a  millet  seed.  The  cavernous  form  causes  a  condition 
knowTi  as  macroglossia.  It  is  usually  congenital,  or  develops  in  early 
infancy  (Fig.  84),  and  is  not  infrequently  accompanied  by  the  capillary 
form.  It  may  cause  such  an  enlargement  of  the  tongue  that  it  cannot 
be  withdrawn  into  the  mouth  but  constantly  protrudes  through  the  Kps. 
It  causes  disturbances  in  the  development  of  the  Hps,  jaws,  and  teeth 
through  pressure. 

One  of  the  characteristics  of  this  form  of  new  growths  is  the  fact  that 
it  is  subject  to  recurrent  attacks  of  inflammation,  which  are  accompanied 
by  great  swelHng  and  pain  in  the  affected  portion.  If  the  condition  is 
circumscribed  it  may  resemble  a  sarcoma  of  the  tongue,  but  can  be 
readily  differentiated  from  it  by  the  histon,-  of  its  having  been  present 
since  birth  and  the  fact  that  its  growth  is  far  slower  than  that  of  a 
sarcoma. 

Papilloma  of  the  tongue  occurs  in  the  form  of  soft,  pedunculated 
tumors  which  can  be  readilv  diagnosed. 


MALIGNANT  TUMORS  OF  THE  TONGUE. 

Sarcoma. — Sarcoma  of  the  tongue  is  quite  rare.  It  has  only  been 
found  in  young  girls  and  women.  It  grows  rapidly  and  ulcerates  at  quite 
an  early  stage.  It  must  be  differentiated  from  gumma  and  from  carcinoma 
of  the  tongue.  This  can  be  done  by  remembering  the  fact  that  gumma  is 
usually  multiple,  even  though  it  be  present  in  the  form  of  a  nodular  growth 
within  the  substance  of  the  tongue.  Gummata  occur  at  a  later  period 
of  Hfe  and  there  is  usually  a  history  of  syphiHs  or  the  evidences  of  the 
disease  elsewhere.    The  growth  is  far  less  rapid  than  is  that  of  a  sarcoma. 

From  carcinoma  a  sarcoma  of  the  tongue  can  be  differentiated  by 
the  fact  that  the  induration  is  much  harder  in  a  carcinoma  than  in  sar- 
coma and  that  the  former  appears  at  a  later  period  in  hfe. 

Carcinoma  of  the  Tongue. — This  may  appear  in  one  of  four  forms: 


o 
■-I 

> 
2; 

^ 

0 

o 

> 

CL 

S 

0 

> 

^ 

& 
p" 

2; 

a 

0 
PC 

Q 

0 

< 

^, 

<? 

C/3 

Cfi' 

c. 

w 

0 

n 

rr 

> 

n 
> 

U2 

p] 

H 

M 

w 

P 

^^ 

w 

0 

^ 

■^ 

H 

>^ 

G 

1:3 

r 

Cfi 

g 

'H- 

^ 

t~> 

0 

> 

CA     .w        Wo 


"■ 

Y' 

H 

0 

0 

0 

t/3 

p 

3' 

ni 

2; 
0 

> 

0 

•-< 

crq 

,_, 

d 

0 

•Z 
> 

"O 

■-1 

0 

p 

bd 

ET 

'  ' 

0 

t-' 

p" 

CO 

►< 

K 

0 

p" 

0 

►T3 

^ 

t-+i 

oq 

n 

!? 

> 

G 

ff- 

3 

<^ 

2 

00 

rc 

rti 

w 

0 

Cn 

a 

D 

0 

*TIU 

0 

S 

> 

0 

-13^ 

z 

£■ 

c 

<^ 

^ 

0 

rt 

t/i' 

W 

^^ 

0 

0 

0 

P 

H 

C 

K 

oq 

Si? 

c 

rc 

0 
a- 

MALIGNANT    TUMORS    OF   THE    TONGUE. 


135 


(a)  As  a  fissure,  with  indurated  edges;  (b)  as  a  carcinomatous  ulcer; 
(c)  as  a  warty  growth  whose  base  has  become  indurated,  and  (d)  as  a 
hard  nodule  in  the  substance  of  the  tongue. 

Usually  one  does  not   see  carcinoma  in  the  nodular  form.     Ordi- 
.  narily  it  appears  as  an  ulcer  or  fissure. 

According  to  Butlin,  the  most  important  precancerous  condition 
is  the  papilloma,  which  precedes  the  development  of  carcinoma.     The 
warts  enlarge  in  size,  the  base  becomes  harder,  and  sooner  or  later  ulcer- 
ation   occurs.        Not    infre- 
quently the  warts  are  present 
(Fig.  86)  upon  a  tongue  which 
is   the   seat  of  an  extensive 
leukoplakia. 

The  least  frequent  form 
of  carcinoma  of  the  tongue  is 
the  nodule  in  its  substance. 
It  must  be  differentiated  from 
sarcoma  or  gumma  in  the  sub- 
stance of  the  tongue  before  it 
begins  to  ulcerate.  This  has 
been  referred  to  above,  under 
the  head  of  sarcoma  of  the 
tongue. 

The  characteristics  of  car- 
cinoma of  the  tongue,  after 
ulceration  has  once  begun, 
are: 

(a)  It  appears  most  fre- 
quently along  the  edges  or 
under  surface  of  the  tongue, 
(b)  there  is  early  enlargement 
of  the  submaxillary  and  deep 
cervical  lymph-nodes;  (c)  the 
edges  of  the  ulcer  are  everted  and  very  firm,  and  (d)  the  floor  of  the 
ulcer  is  covered  with  a  large  amount  of  necrotic  epithehum. 

There  is  usually  severe  pain,  which  radiates  to  the  car.  In  the  later 
stages  the  carcinomatous  ulcer  has  a  very  fetid  odor,  is  very  painful,  and 
severe  hemorrhages  may  occur. 

Carcinoma  of  the  tongue  must  be  differentiated  from  the  following 
conditions: 

(a)  Dental  or  Decubital  Ulcers. — These  arc  present  along  the  edges 


Fig.  86. — Papillary  Form  of  Carcinoma  of  Tongue  De- 
veloping ON  Psoriasis  Lingd.s  (Jonathan  Hutchinson). 


136  SURGICAL   AFFECTIONS    OF   THE   HEAD. 

of  the  tongue  opposite  a  sharp  tooth.  The  ulcer  is  never  as  deep  as 
that  of  a  carcinoma,  nor  are  the  edges  as  indurated,  and  there  is  no 
enlargement  of  lymph-nodes.  The  ulcer  heals  in  a  few  days  if  the  tooth 
is  either  extracted  or  the  sharp  edge  filed  down. 

(b)  From  Tubercular  Ulcers. — These  never  show  the  Induration 
which  characterizes  the  carcinomatous  ulcer.  The  tubercular  ulcer  is 
quite  shallow,  usually  with  undermined,  not  raised,  edges,  and  there  is 
no  lymph-node  enlargement.  They  occur  at  an  earlier  age  and  are 
usually  secondary  to  tuberculosis  of  the  larynx  or  lungs. 

(c)  From  syphilis  the  question  of  differentiation  most  often  arises  in 
the  case  of  gummatous  ulcers.  The  diagnosis,  as  will  be  seen  in  Figs. 
82  and  83,  is  at  times  exceedingly  difficult.  In  the  case  shown  in  the 
illustrations,  the  patient  gave  a  distinct  history  of  syphiHs  and  had  well- 
marked  symptoms  of  tabes  dorsalis.  The  first  diagnosis  made  in  the 
case  was  that  of  epithelioma  of  the  tongue,  on  account  of  the  marked 
induration,  and  raised,  everted  edges,  and  deep  ulceration.  The 
administration  of  iodid  of  potassium  caused  a  marked  improvement  in 
the  condition,  the  induration  and  ulceration  disappearing  to  a  great 
extent.  In  a  short  time,  however,  these  signs  recurred,  in  spite  of  the 
continued  administration  of  the  drug.  At  the  time  the  diagnosis  of 
epithehoma  was  first  made,  there  was  an  accompanying  enlargement 
of  the  submaxillary  lymph-nodes  on  the  side  upon  which  the  ulcer  was 
situated,  and  this  was  thought  to  confirm  the  diagnosis  of  epithehoma. 
The  final  diagnosis  made  in  this  case,  after  removal  of  the  tongue,  was 
that  it  had  been  a  carcinoma  of  the  tongue,  which  had  developed  upon  a 
tertiary,  i.  e.,  gummatous  ulcer. 

This  case  illustrates  the  difficulties  of  diagnosis  between  epithehoma 
and  tertiary  syphilis.  According  to  Jonathan  Hutchinson,^  at  least 
30  per  cent,  of  the  patients  with  epithelioma  give  the  history  of  pre- 
vious syphihs.  An  accurate  diagnosis  can  be  made  in  the  majority  of 
cases,  but  in  some  only  the  microscopic  examination  decides. 

A  therapeutic  test  may  at  times  be  fallacious,  either  from  the  fact 
that  carcinoma  may  improve  after  the  hygiene  of  the  mouth  has  been 
attended  to,  or  that,  as  in  the  case  illustrated  in  Fig.  82,  the  carcinoma 
has  developed  upon  a  gummatous  ulcer. 

In  general,  the  following  may  be  taken  as  the  chief  differential 
points,  between  epithehomatous  and  gummatous  ulcers: 

'  "  Practitioner,"  May,  1903. 


MALIGNANT   TUMORS    OF    THE    TONGUE. 


137 


Gummatous  Ulcer. 

1.  Appears  usually  multiple  on  dorsum. 

2.  May  occur  at  any  age.  2, 

3.  But  little  if  any  enlargement  of  lymph-         3. 

nodes. 

4.  But  little  pain.  4 

5.  Induration   less   marked  than   in   car-         5 

cinoma. 

6.  lodid    of    potassium    causes    marked         6 

improvement  within  a  week. 

7.  Evidence  of  tertiary  disease  elsewhere.         7 


Carcinomatous  Ulcer. 

1.  Appears  on  sides  of  tongue  and  floor 
of  mouth. 

2.  May  occur  as  early  as  thirty. 

3.  Early  and  indurated  enlargement  of 
submaxillary  and  deep  cervical 
lymph-nodes. 

4.  Considerable  pain,  radiating  to  ear. 

5.  Very  marked  induration.  Edges  raised 
and  everted. 

6.  No  improvement  or  only  slight,  unless 
carcinoma  has  developed  upon  a 
gummatous  ulcer. 

No  evidence  of  tertiary  disease,  unless 
carcinoma  has  developed  in  an  indi- 
vidual with  previous  syphilis. 


Carcinoma  of  the  floor  of  the  mouth  may  spread  to  the  under  sur- 
face of  the  tongue,  so  that  it  is  at  times  difficult  to  ascertain  where  the 
disease  began.  There  is  only  one  condition  which  it  may  at  times  be 
necessary  to  differentiate,  under  these  circumstances,  and  that  is  the 
ulceration  due  to  the  infection  of  the  tissues  around  a  salivary  calculus. 
There  is  not  infrequently  considerable  painful  induration  around  such 
a  calculus,  with  ulcer  formation,  the  ulcer  being  covered  with  foul 
granulations.  It  can  be  differentiated  from  a  true  carcinoma  by  the 
fact  (a)  that  the  induration  is  never  as  marked  as  in  carcinoma;  (b)  by 
the  use  of  a  probe  one  can  find  the  calculus,  and  (c)  as  a  rule  there  is  no 
induration  of  the  lymph-nodes.  It  is  aknost  impossible  to  make  a 
diagnosis  between  an  unbroken  gumma  and  the  nodular  form  of  car- 
cinoma, which  occurs  in  the  substance  of  the  tongue,  except  perhaps 
the  fact  that  the  nodular  form  of  carcinoma  is  single,  while  the  gumma 
is  multiple.  There  are  other  signs  of  syphihs  or  the  history  of  syphihs 
in  the  case  of  a  gumma. 

The  only  other  conditions  of  the  tongue  which  need  to  be  mentioned 
are  lingual  goiter  and  lingual  tonsils. 

Lingual  goiter  (Fig.  77)  is  an  enlargement  of  the  upper  end  of  the 
original  thyroglossal  duct,  which  has  its  termination  close  to  the  foramen 
cecum  at  the  posterior  portion  of  the  dorsum  of  the  tongue.  Ordinarily 
a  lingual  goiter  causes  no  symptoms,  except  that  when  it  begins  to  grow 
it  may  cause  some  difficulty  in  swallowing.  It  may  be  as  large  as  a 
walnut  and  yet  cause  no  inconvenience. 

The  first  symptom  is  generally  an  uncomfortable  feeling  at  the  base 
of  the  tongue,  a  fullness  in  the  throat  accompanied  by  a  frequent  desire 
to  swallow.     There  is  a  change  in  the  voice,  which  becomes  thicker 


138  SURGICAL    AFFECTIONS    OF   THE    HEAD. 

and  nasal  in  quality/  There  may  be  fits  of  coughing.  Only  in  the 
case  of  the  largest  tumors  is  the  respiration  interfered  with. 

Later  in  the  disease  there  are  recurrent,  profuse  hemorrhages. 
These  occur  at  any  time,  without  any  apparent  cause,  the  patient  being 
simply  aware  that  the  mouth  is  filled  with  fluid,  which  on  expectoration 
proves  to  be  blood. 

The  presence  of  the  growth  can  only  be  determined  by  the  use  of 
the  lar}Tigoscope  or  the  finger.  The  tumor  is  soft,  reddish  in  color, 
shows  no  ulceration  or  induration,  or  enlarged  l}Tnph-nodes. 

The  diagnosis  can  be  made  from  the  facts  (a)  that  it  is  soft,  not 
indurated  or  ulcerated;  (b)  it  is  not  accompanied  by  enlarged  l^Tnph- 
nodes,  and  (c)  its  course  is  a  verv'  chronic  one.  The  cases  so  far  reported 
appear  to  have  occurred  exclusively  in  women  between  the  ages  of 
fifteen  and  forty. 

The  differential  diagnosis  of  a  hngual  goiter  includes : 

(a)  Dermoid  cysts.  This  is  the  only  condition  which  offers  any 
difficulty.  It  is  generally  yellow,  grows  rapidly,  pits  on  pressure  and  is 
not  vascular. 

(b)  Angioma  is  a  quite  common  tumor  at  the  base  of  the  tongue 
and  may  give  rise  to  hemorrhages.  It  is,  however,  easily  reduced  by 
pressure,  refilling  immediately,  and  is  of  a  bluish  color. 

The  Lingual  Tonsil. — The  enlargements  of  this  group  of  adenoid 
tissue  on  the  dorsum  of  the  tongue,  near  the  foramen  cecum,  may  cause 
some  symptoms,  especially  if  they  become  inflamed  or  enlarged.  These 
are  pain  in  swallowing,  aching,  irritable  throat,  and  coughing. 

The  diagnosis  can  only  be  made  by  the  use  of  the  lar}Tigoscopic 
mirror.  One  then  sees  whitish  folHcles,  swollen  and  filled  with  secretion, 
extending  in  either  direction  from  the  foramen  cecum.  At  times  one  of 
these  may  suppurate  and  be  accompanied  by  parenchymatous  glossitis. 


Affections  of  the  Salivary  Glands. 

Injuries. — Wounds  of  the  submaxillary  and  subhngual  glands  are 
so  rare  that  only  those  of  the  parotid  will  be  referred  to. 

Injuries  of  the  parotid  gland  itself  not  infrequently  occur  in  connec- 
tion with  those  of  the  face. 

Wounds  of  the  gland  parenchyma  itself  are  of  but  little  consequence, 
since  a  sahvar}'  fistula  rarely  follows  such  an  injury.  Chief  interest  lies 
in  injuries  of  the  vessels  passing  through  the  gland  and  of  the  facial 
nerve,  which  divides  within  the  capsule.     The  vessels  which  pass  through 

^Storrs:  "Annals  of  Surgery,"    1904. 


AFFECTIONS    OF   THE    SALIVARY   GLANDS. 


139 


the  gland  and  might  be  injured  by  a  penetrating  wound  are  the  temporo- 
maxillary  (posterior  facial)  vein  and  the  termination  of  the  external 
carotid  artery.  The  recognition  of  their  injury  does  not  differ  from 
that  of  similar  structures  elsewhere. 

An  injury  of  the  facial  tierve  during  its  passage  through  the  parotid 
capsule  is  recognized  by  the  paralysis  of  the  muscles  of  expression  (Fig. 
87).  The  naso-labial  fold  upon  the  side  of  the  injury  is  flattened,  there 
is  inability  to  close  the  eyelids  and  to  show  the  teeth  or  to  whistle. 

Injuries  of  the  parotid  duct  are  more  important  than  those  of  the 
gland  itself.  It  may  be  wounded  while  (a)  it  is  still  in  the  parotid  cap- 
sule, (b)  during  its  pas- 
sage across  the  mas- 
seter  muscle,  and  (c) 
while  penetrating  the 
tissues  of  the  cheek  to 
open  into  the  mouth. 
The  recognition  of 
such  injury  is  usually 
not  difficult.  Saliva  is 
seen  to  escape  from  a 
wound  in  the  cheek, 
especially  during  mas- 
tication. The  diag- 
nosis is  confirmed  by 
inserting  a  fine  probe 
through  the  opening 
of  Steno's  duct  where 
it  opens  into  the  mouth 
opposite  the  second 
upper     molar     tooth. 

The  probe  will  pass  through  the  opening  in  the  duct  and  emerge  in  the 
cheek  wound  externally.  One  can  also  observe  the  escape  of  colored 
liquids  such  as  methylene-blue  when  injected  into  the  buccal  orifice  of 
Steno's  duct. 

A  salivary  fistula  is  rarely  congenital.  In  the  majority  of  cases  it 
follows  an  injury  to  the  gland  or  its  duct  or  it  is  the  result  of  abscess 
formation  in  the  gland  or  in  the  duct  with  subsequent  ulceration  of  the 
overlying  tissues.  In  both  cases  there  is  an  external  opening,  either 
over  the  glands  or  along  the  course  of  the  duct,  lined  by  granulations 
from  which  a  watery  fluid  escapes. 

The  secretion  of  a  duct  fistula  is  much  greater  than  that  of  a  glan- 


FiG.  87. — Left-sided  Facial  Paralysis. 
Involving  all  three  groups  of  muscles  supplied  by  the  seventh 
cranial  nerve,  namely,  the  eye,  nasal  and  labial  groups.  Note  the 
obliteration  of  the  naso-labial  fold  on  the  side  of  paralysis,  the  droop- 
ing of  the  left  angle  of  the  mouth,  the  inabihty  to  close  the  left  eye- 
lid, and  loss  of  action  of  the  muscles  of  the  eyebrows. 


I40  SURGICAL  AFFECTIONS  OF  THE  HEAD. 

dular  one.  In  the  duct  fistulae  there  is  an  absence  of  any  ejection  of 
saliva  from  the  opening  of  the  duct  within  the  mouth.  This  is  best 
seen  when  the  cheek  is  retracted  while  the  opening  of  the  duct  into 
the  mouth  is  observed. 

Salivary  Calculi. — The  majority  of  these  occur  in  the  excretory  duct 
(Wharton's)  of  the  submaxillary  gland.  They  are  very  rare  in  Steno's 
duct.  The  calculi  are  usually  the  size  of  a  pea  or  bean  but  occasionally 
attain  to  that  of  a  pigeon's  or  hen's  egg.  Salivary  calculi  may  give 
rise  to  the  following  clinical  pictures: 

1.  They  may  remain  dormant  for  many  years  and  not  give  rise  to 
any  symptoms. 

2.  They  give  rise  to  acute  attacks  of  salivary  retention.  These  are 
recognized  by  the  sudden  appearance,  usually  after  eating,  of  pain  along 
the  duct,  accompanied  by  a  markedly  tender  enlargement  over  the 
normal  situation  of  the  gland  whose  duct  is  blocked.  After  a  few  hours 
there  is  a  sudden  discharge  of  saliva  into  the  mouth,  and  the  swelling  and 
tenderness  rapidly  disappear.  With  such  a  history  of  recurrent  swelling 
one  must  always  pass  a  probe  into  the  duct  or  palpate  along  its  course 
for  the  calculus,  which  can  usually  be  readily  felt. 

3.  There  may  be  inflammation  of  the  tissues  around  the  stone  and 
resultant  abscess  formation.  This  clinical  form  is  characterized  by  the 
appearance  of  great  pain,  tenderness,  and  induration  along  the  course 
of  one  of  the  salivary  ducts.  In  the  case  of  Wharton's  duct  this  is 
most  marked  along  the  floor  of  the  mouth,  while  in  that  of  Steno's  duct 
it  is  best  felt  with  the  iinger  while  palpating  the  inside  of  the  cheek  or 
externally  along  the  course  of  the  duct.  In  the  latter  location,  i.  e., 
Steno's  duct,  the  first  sign  may  be  the  appearance  of  an  induration  in 
the  middle  of  the  cheek,  accompanied  by  redness  and  swelling  of  the 
skin  lying  over  it.  The  diagnosis  can  be  made  from  the  location  of  the 
abscess  and  the  absence  of  any  other  cause. 

4.  A  salivary  calculus  may  appear  as  an  ulceration  on  the  floor  of 
the  mouth  or  on  the  inside  of  the  cheek.  The  ulcer  has  indurated 
edges  and  a  dirty  foul-smelling  base.  Its  resemblance  to  carcinoma 
has  already  been  referred  to.  The  diagnosis  can  only  be  made  by  the 
use  of  the  probe  or  the  finger,  which  encounter  the  calculus  lying  at  the 
bottom  of  the  crater-like  ulcer. ' 

Inflammatory  Affections. — These  may  be  acute  and  chronic. 
The  acute  may  occur  (a)  as  an  epidemic  variety  of  acute  inflamma- 
tion of  the  parotid  or  submaxillary  glands  commonly  called  "mumps," 
This  is  fully  described  in  the  text-books  on  internal  medicine  and  pre- 
sents but  Httle  difficulty  in  diagnosis.     If,  however,   a   complication 


AFFECTIONS    OF   THE    SALIVARY    GLANDS.  I4I 

such  as  orchitis  or  oophoritis  occurs,  it  is  of  great  diagnostic  importance 
to  obtain  the  history  of  a  preceding  acute  swelling  in  front  of  the  ears 
or  below  the  jaw,  which  lasted  for  a  week  to  ten  days. 

(b)  The  other  form  of  acute  inflammation  of  the  sahvary  glands 
occurs  as  a  complication  of  typhoid  and  other  of  the  acute  infections 
diseases.  It  may  also  occur  after  laparotomies  and  is  then  given  the 
special  name  of  "coeliac  parotitis." 

These  so-called  acute  secondary  inflammations  almost  always  in- 
volve the  parotid  gland.  The  diagnosis  can  be  made  from  the  appear- 
ance of  severe  pain  at  first  referred  to  the  angle  of  the  lower  jaw  and 
later  in  front  of  the  ear  and  greatly  increased  by  movements  of  the  jaw. 
The  onset  of  swelhng  is  rapid  and  there  is  marked  edema  and  redness 
of  the  overlying  skin.  If  suppuration  occurs  the  skin-infiltration  and 
redness  increase  and  there  is  soon  distinct  fluctuation.  The  abscess 
may  burst  externally  either  through  the  external  auditory  canal  or  the 
cheek.  Such  a  parotid  suppuration  may  be  the  starting-point  of  a 
retropharyngeal  and  periesophageal  phlegmon  or  the  infection  may 
spread  to  the  skull  and  give  rise  to  a  fatal  meningitis. 

Tuberculosis  of  the  Salivary  Glands. — This  is  a  very  rare  affection, 
especially  as  a  primary  disease.  It  is  not  infrequent  as  the  result  of  an 
extension  of  a  tuberculosis  of  the  lymph-nodes  contained  within  the 
parotid  capsule.  In  either  form  there  is  moderate  enlargement  of  the 
gland  and  fistulse  form,  fined  by  flabby,  often  caseous,  granulations. 

Syphilis. — This  form  of  chronic  inflammatory  enlargement  usually 
occurs  in  the  tertiary  stage.  The  disease  almost  always  involves  the 
parotid,  causing  a  soft  tumor-hke  swelhng.  The  diagnosis  of  its 
syphilitic  nature  can  only  be  made  from  the  histor}^  and  its  rapid 
disappearance  under  appropriate  treatment. 

Tumors  of  the  Salivary  Glands. — In  attempting  to  make  a  diag- 
nosis of  the  nature  of  an  enlargement  of  one  of  the  sahvary  glands  one 
must  bear  in  mind  the  following  possibihties : 

1.  If  the  onset  is  sudden  the  enlargement  is  either  of  an  acute 
inflammator}'  nature  or  is  due  to  an  acute  retention  of  secretion  through 
obstruction  of  the  excretor}'  duct. 

2.  If  the  onset  has  been  slow'and  the  increase  in  size  gradual  it  may 
be  due  (a)  to  a  retention-cyst,  (b)  to  chronic  inflammatory  changes  as  a 
result  of  syphilis  or  tuberculosis,  or  (c)  to  a  neoplasm. 

Retention-cysts  and  neoplasms  occur  far  more  frequently  in  the 
parotid  than  in  cither  the  submaxillary  or  sublingual  glands. 

Reteniion-cysts  differ  from  the  condition  described  on  page  125  as 
acute  dilatation  of  the  ducts  or  glands  themselves  due  to  transitory  ob- 


142  SURGICAL   AFFECTIONS    OF   THE    HEAD. 

struction  to  the  flow  of  saliva.  Retention-cysts  are  permanent  and  are 
due  to  a  complete  and  chronic  obstruction  of  the  duct.  The  accu- 
mulation of  secretion  may  take  place  either  in  the  duct  or  in  the 
gland.  In  the  former  case  (cysts  of  the  salivary  ducts)  the  condition 
must  be  thought  of  when  an  elongated  sausage-shaped  fluctuating 
tumor  is  found  in  a  location  corresponding  to  that  of  either  Steno's  or 
Wharton's  duct. 

The  swelhng  is  quite  sharply  demarcated  and  is  not  tender.  Infec- 
tion of  the  contents  may  occur  with  all  the  signs  of  inflammation,  e.  g., 
pain,  redness,  etc.  If  such  infection  occur  the  swelling  may  resemble, 
in  Steno's  duct,  an  inflamed  lymph-node  in  the  cheek.  This,  however, 
is  a  very  rare  condition  and  can  be  readily  excluded  by  its  more  super- 
ficial location  and  the  absence  of  a  primary  focus. 

Cysts  of  the  salivary  glands  give  rise  to  a  visible  and  palpable  en- 
largement of  the  gland  involved,  especially  if  the  cyst  is  situated  close 
to  the  surface.  They  are  very  rare  in  the  parotid  and  submaxillary, 
but  occur  more  often  in  the  sublingual  gland.  In  the  latter  the  condi- 
tion is  known  as  ranula  (see  Fig.  78)  and  can  be  recognized  by  the 
location  at  the  floor  of  the  mouth,  and  by  its  fluctuation  and  trans- 
lucency. 

Tumors  of  the  Salivary  Glands. 

In  the  diagnosis  of  a  tumor  of  the  saHvary  glands  one  must  consider 
(a)  the  size  of  the  growth;  (b)  the  condition  of  its  surface,  whether 
smooth  or  nodulated;  (c)  its  consistency,  whether  fibrous,  cartilaginous 
soft,  or  cystic;  (d)  its  clinical  history,  whether  it  remained  stationary 
for  many  years  and  then  suddenly  increased  in  size,  whether  its  growth 
has  been  rapid  from  the  time  it  was  first  noticed  or  whether  it  has 
remained  of  about  the  same  size  for  a  considerable  period. 

Tumors  of  the  salivary  glands  are  best  divided  into  the  following 
groups : 

(  (a)  Fibromata. 

1.  Those  of  the  benign  connective-tissue  type -<  (b)  Angiomata. 

t  (c)  Lipomata. 

2.  Mixed  tumors  (including  sarcomata). 

3.  Carcinomata. 

I.  Benign  Connective-tissue  Type: 

(a)  Fibromata. — These  are  very  rare.  They  are  firm,  encapsulated 
growths  which  run  a  benign  clinical  course.  They  grow  very  slowly 
and  do  not  tend  to  recur  when  removed. 

(b)  Angiomata. — These  are  also  very  rare  and  usually  occur  in  chil- 


AFi'ECTIONS    OF   THE    SALIVARY   GLANDS.  I43 

dren.  They  greatly  resemble  simple  hypertrophy  and  form  irregular 
soft  tumors. 

(c)  Lipomata. — But  few  cases  of  this  form  of  tumor  have  been  re- 
ported and  of  these  all  occurred  in  the  parotid.  They  raise  the  gland 
itself,  are  soft,  and  often  lobulated.  The  diagnosis  is  seldom  pos- 
sible before  operation. 

2.  Mixed  Tumors  (Including  Sarcomata). — It  has  been  fre- 
quently observed  that  sarcomata  of  the  salivary  glands  differed  clini- 
cally from  the  same  form  of  tumors  as  found  elsewhere,  both  in  their 
clinical  and  pathologic  characteristics.  Since  the  systematic-  study 
of  these  tumors,  by  Hinsberg,^  Wilms,"  Wood^  and  others,  it  has  been 
found  that  the  majority  of  tumors  of  the  salivary  glands  belong  to  the 
class  of  mixed  growths  and  that  pure  sarcomata  are  comparatively  rare. 
Of  fifty-nine  cases  examined  by  Wood,  all  but  four  belonged  to  the  mixed 
tumors.  They  occui"  about  twice  as  frequently  in  the  parotid  as  in  the 
submaxillary  and  usually  between  the  ages  of  twenty  to  forty.  They 
contain  elements  from  both  the  epiblast  and  mesoblast  in  most  intimate 
relation  to  each  other.  The  stroma  contains  embryonic  connective 
tissue,  cartilage,  bone,  fat,  and  lymphoid  tissue.  There  is  also  epithe- 
lium present  in  about  24  per  cent,  of  the  cases. 

The  mixed  tumors  of  the  salivary  glands  are  found,  as  a  rule,  to  be 
encapsulated,  lobular  growths,  with  harder  and  softer  areas,  the  denser 
portions  being  due,  as  a  rule,  to  the  presence  of  cartilage  or  firm  con- 
nective tissue.  They  can  be  divided  macroscopically  into  three  great 
rough  groups  with  characteristic  morphology  and  to  a  certain  extent 
with  a  definite  clinical  course: 

1.  Very  fibrous  tumors  with  very  little  cellular  structure  and  with 
but  little  mucous  degeneration  and  no  cartilage. 

2.  Very  hard  tumors  containing  large  masses  of  cartilage  and  but 
little  connective  tissue  or  cellular  parenchyma  (Fig.  88). 

3.  Soft,  very  cellular  growths  with  transparent  trabeculas  of  mucous 
tissue  surrounding  areas  which  are  opaque  and  yellow,  which  on  micro- 
scopic examination  will  be  found  to  be  dense  cellular  areas,  the  color 
being  occasionally,  though  not  always,  due  to  fatty  degeneration  or 
necrosis  of  the  cells. 

The  first  and  second  forms  are  usually  benign  in  their  clinical 
course,  while  the  third  form  is  likely  to  recur  locally  or  to  pursue  an  ex- 
ceedingly malignant  course. 

^Hinsberg:    "Deutsche  Zeitschr.  f.  Chirurgie,"  Vol.  6i. 
^  Wilms:    "Deutsche  Zeitschr.  f.  Chirurgie,"  Vol.  69. 
^Wood:    "Annals  of  Surgery,"  Jan.  and  Feb.,  1904. 


144 


SURGICAL    AFFECTIONS    OF    THE    HEAD. 


The  skin  is  freely  movable  over  the  benign  gro^Yths.  The  ear  may 
be  distorted  or  pressed  entirely  backward  by  a  large  tumor  in  the  parotid 
region,  especially  if  the  growth  has  extensions  behind  the  angle  of  the 
jaw  and  is  therefore  unable  to  expand  anteriorly. 

An  average  of  the  cases  of  mixed  tumors  in  the  Kterature  shows  that 
some  25  per  cent,  undergo  changes  which  express  themselves  in  a  cHn- 
ically  malignant\'ourse,  while  about  30  per  cent,  recur  after  operative 


Fig.  88. — CHON"DROSARC0iL\  OF  Parotid  Glant). 
Note  how  the  tumor  arises  in  the  parotid  region  and  extends  toward  and  below  the  lower  jaw  and  its  nodulated 

surface. 


removal,  though  some  of  these  recurrences  may  be  checked  by  a  second 
and  more  complete  removal. 

The  mahgnancy  of  these  tumors  can  be  judged  to  a  certain  extent  by 
their  slo\\Tiess  of  growth  and  their  physical  characteristics.  The  hard 
fibrous  and  cartilaginous  tumors  are  apt  to  be  benign,  while  the  soft 
cellular  tvpes  are  hkelv  to  prove  mahgnant.  But  frequently  a  tumor 
which  has  remained  for  a  long  time  quiescent  wiU  begin  a  most  rapid 
growth,  and  in  a  few  months  increase  in  size  more  than  during  its  entire 
previous   existence.      This   sudden   and   rapid  growth  is  accompanied 


AIFECTIOXS    OF    THE    SALIVARY    GLANDS.  145 

by  the  clinical  and  microscopic  evidences  of  malignancy,  and  the 
tumor  spreads  through  the  surrounding  tissues,  involves  the  skin  and 
the  sahvar}'  glands,  and  may  form  metastases. 

Carcinomata  of  the  Parotid. — These  occur  in  people  between  forty 
and  sixty  years  of  age  and  are  apt  to  be  very  painful.  They  may  grow 
either  slowly  as  a  scirrhous  form,  causing  considerable  retraction  of  the 
skin,  or  as  a  medullar}^  form,  growing  ver}*  rapidly  and  causing  ulcera- 
tion of  the  overlying  skin.  Carcinomata  of  the  parotid  are  apt  to  be 
ver}-  painful  and  also  cause  early  enlargement  of  the  lymph-nodes  of 
the  neck  on  the  corresponding  side. 

The  medullar}-  form  of  carcinoma  resembles  greatly  that  of  the  same 
form  of  carcinoma  of  the  breast.  It  grows  ver}'  rapidly  and  may  occur 
at  a  comparatively  early  period,  e.  g.,  at  the  age  of  forty  years,  and  is 
readily  recognized  not  only  by  the  rapidity  of  the  growth,  but  from  the 
early  involvement  of  the  skin.  The  latter  is  not  movable  over  the 
tumor  as  in  the  other  forms  of  parotid  tumors.  The  scirrhus  form  re- 
sembles the  scirrhus  form  of  carcinoma  of  the  breast,  causing  not  only 
retraction  of  the  skin  of  the  parotid  region  but  also  an  invasion  of  the 
skin  itseh  in  the  form  of  a  diffuse  carcinomatous  lymphangitis,  giving 
rise  to  the  same  variety  of  board-hke  infiltration  which  occasionally 
occurs  in  carcinoma  of  the  breast.  To  this  latter  condition  the  name 
armor-Hke  cancer  has  been  given. 

Diagnosis  of  the  Tumors  of  the  Parotid  in  General. — In 
attempting  to  make  a  diagnosis  of  tumor  of  the  parotid  one  must 
bear  the  different  groups  in  mind.  Tumors  of  the  parotid  cause  a 
characteristic  prominence  (Fig.  88)  just  in  front  of  the  ear,  which  latter 
is  raised  away  from  the  head.  They  may  either  grow  toward  the  neck, 
forming  a  ver}'  prominent  tumor,  or  toward  the  depth,  that  is,  toward 
the  pharynx.  In  some  cases,  enlargement  of  the  parotid  of  an  inflamma- 
tor}-  nature,  such  as  (a)  retention-cysts,  due  to  saHvar}-  calcuh,  (b)  of  the 
induration  described  as  occurring  in  syphilis,  or  (c)  enlarged  lymph- 
nodes  lying  within  and  upon  the  parotid,  must  be  excluded. 

Lymph-nodes  have  at  times  the  consistency  of  the  soft  variety  of 
mixed  tumors.  If  they  lie  within  the  capsule  and  have  enlarged  rapidly, 
it  may  be  almost  impossible  to. make  a  diagnosis.  If,  however,  they  He 
outside  of  the  capsule  they  are  movable  upon  the  underlying  parotid. 

As  to  the  variety  of  tumors,  those  belonging  to  the  first  group  of  mixed 
tumors  are  usually  quite  small,  not  nodular,  movable  within  the  capsule 
of  the  gland,  and  give  the  historv'of  having  been  present  for  a  long  time. 
Those  of  the  second  group  of  mixed  tumors  contain  one-fourth  of  all 
the  tumors  appearing  in  the  parotid.     They  are  distinctly  nodulated, 


146  SURGICAL    AFFECTIONS    OF   THE   HEAD. 

have  the  characteristic  consistency  of  cartilage  and  the  history  of 
long  duration,  as  a  rule,  although  a  rapid  increase  in  growth  may  sud- 
denly take  place. 

A  soft  tumor  usually  belongs  to  the  third  group  of  mixed  tumors. 
These  are  very  cellular  and  give  the  history  of  comparatively  rapid 
enlargement,  or,  on  the  other  hand,  they  remain  benign  for  a  long  time 
and  then  suddenly  grow.  The  latter  is  very  apt  to  happen  after  an 
operation.  This  third  group  has  the  consistency  of  inflamed  lymph- 
nodes  more  than  any  of  the  others,  but  the  inflamed  lymph-node  soon 
becomes  softer  and  fluctuates  distinctly  while  the  neoplasm  is  more  apt 
to  grow  steadily  in  size. 

Carcinomata  of  the  parotid  are  exceedingly  hard,  occur  late  in  life, 
and  give  the  history  of  a  steady,  progressive  enlargement  of  the  gland 
with  frequent  ulceration  of  the  overlying  skin. 

In  the  differential  diagnosis  of  tumors  of  the  parotid,  one  must 
not  forget  (a)  Hpomata  lying  within  the  capsule  of  the  gland,  (b)  tumors 
of  the  temporo-maxillary  joint,  or  (c)  tumors  of  retropharyngeal  origin 
growing  toward  the  temporal  fossa  and  pushing  the  parotid  upward. 

Cystic  tumors  of  the  parotid  give  rise  to  distinct  fluctuation,  are 
of  long  duration,  and  must  always  be  differentiated  from  those  varieties 
of  mixed  tumor  in  which  much  myxomatous  tissue  is  present  which 
may  give  rise  to  a  sense  of  pseudo-fluctuation. 


CHAPTER  II. 

SURGICAL  AFFECTIONS  OF  THE  NECK. 

CONGENITAL  AND  ACQUIRED  MALFORMATIONS. 

Thyroglossal  Fistulae. — These  are  always  found  in  the  median 
hne  of  the  neck.  The  external  opening  may  be  situated  (a)  just  above 
the  isthmus  of  the  thyroid  (Fig.  119),  extending  upward  beneath  the 
skin.  The  fistulous  tract  itself  runs  up  behind  the  body  of  the  hyoid 
where  it  may  form  a  cyst,  (b)  It  may  extend  through  the  substance  of 
the  tongue  and  form  a  cyst  at  the  base  of  the  tongue  (Fig.  77).  A 
fistulous  opening  situated  in  the  median  line  of  the  neck  should  always 
arouse  the  suspicion  of  a  patent  thyroglossal  duct.  The  only  other 
congenital  fistula?  which  occur  in  the  neck  are  situated  along  the  anterior 
border  of  the  sternocleidomastoid.  These  lateral  fistulae  belong  to  the 
branchial  variety  and  are  referred  to  later.  A  thryoglossal  fistulous 
tract  extending  from  the  isthmus  of  the  thyroid  to  the  inner  surface  of 
the  body  of  the  hyoid  can  be  demonstrated  by  injecting  colored  fluids, 
such  as  methylene-blue,  through  the  external  opening.  If  the  tract 
is  pervious  as  far  as  the  foramen  cecum  at  the  base  of  the  tongue,  the 
colored  fluid  will  escape  at  the  latter  place.  At  times  there  is  no  ex- 
ternal opening,  but  only  a  dilated  thyroglossal  duct  filled  with  fluid. 
Under  these  circumstances,  the  diagnosis  can  be  readily  made  if  one 
recalls  the  fact  that  the  only  other  cyst  which  occurs  in  the. middle  of 
the  upper  part  of  the  neck  is  a  dermoid  cyst.  This  is  usually  situ- 
ated more. superficially  and  is  more  often  in  the  submental  region.  It 
is  also  of  larger  size  and  of  firmer,  more  doughy,  consistency  than  a 
thyroglossal  cyst.  The  diagnosis  of  thyroglossal  cysts  at  the  base  of 
the  tongue  was  taken  up  on  page  138. 

Branchial  Fistulae. — These  are  usually  unilateral,  and  the  external 
openings  are  more  often  situated  just  above  the  sternoclavicular  joint 
or  at  the  middle  of  the  sternocleidomastoid.  The  internal  open- 
ings are  usually  found  on  the  tonsil,  the  lateral  wall  of  the  pharjux, 
or  on  the  pillars  of  the  fauces.  The  fistula  may  be  complete,  having 
Ijoth  internal  and  external  openings,  or  incomplete,  having  only  an 
internal  or  external  opening,  as  the  case  may  be.  The  incomplete 
internal  fistulas  are  fined  with  cyhndric,  and  the  incomplete  external 

147 


148 


SURGICAL   AFFECTIONS    OF   THE   NECK. 


fistulas  with  squamous  epithelium.  From  the  external  opening  a  small 
amount  of  mucus  escapes.  It  may  close,  the  secretion  being  retained, 
and  suppuration  occur.  The  course  of  a  branchial  fistula  can  be  dem- 
onstrated, as  in  the  case  of  thyroglossal  fistula,  by  injecting  colored 
fluids.  It  can  be  felt  at  times  as  a  firm  cord  through  the  skin,  ex- 
tending upward  along  the  anterior  border  of  the  sternocleidomastoid 
toward  the  region  of  the  tonsil.  The  deeper  portions  of  a  branchial 
fistula  may  dilate  to  form  a  cyst. 

Carcinoma  may  originate  from  the  epithehum  of  branchial  fistulse. 
Branchial  cysts  and  branchiogenic  carcinomata  are  discussed  in  the 

section     upon      tumors      of     the 
neck. 

The  diagnosis  of  branchial 
fistulas  may  be  made  (a)  from  the 
fact  that  they  usually  occur  in 
young  individuals,  (b)  that  their 
external  opening  is  along  the  ex- 
ternal border  of  the  sternocleido- 
mastoid muscle,  and  (c)  the  secre- 
tion is  a  thin,  viscid  mucus.  In 
the  absence  of  a  suppurating 
lymph-node  which  might  form  a 
sinus  here,  the  diagnosis  is  not 
difiicult.  In  the  case  of  a  sinus 
due  to  tubercular  lymph-nodes, 
the  edges  of  the  sinus  are  often 
lined  by  flabby  caseous  granula- 
tion-tissue, which  will  readily  serve 
to  distinguish  it  from  a  congenital 
fistula. 

Cervical  Rib. — Abnormal 
length  of  the  transverse  process  of  the  seventh  cervical  vertebra  not 
infrequently  gives  rise  to  symptoms  caUing  for  surgical  interference, 
so  that  it  is  important  to  be  able  to  recognize  its  presence.  The 
majority  of  the  cases  in  which  a  diagnosis  has  been  made  during 
hfe  have  occurred  in  adults.  The  bony  outgrowth  is  usually 
bilateral  and  can  be  palpated  as  a  firm,  bony  tumor  just  above  the 
inner  end  of  the  clavicles,  running  backward  and  upward  toward  the 
spine.  Thirty-seven  cases  have  been  reported  in  which  it  has  been  rec- 
ognized during  hfe,  either  through  producing  pressure  on  the  subclavian 
artery  or  some  of  the  branches  of  the  branchial  plexus.     When  the  sub- 


FlG. 


89. — Cervical  Rib  Outlined  on  Surface 

OF  Neck. 
The  cross  indicates  the  tip  of  the  rib. 


CONGENITAL    AND   ACQUIRED    MALFORMATIONS.  I49 

clavian  artery  passes  across  a  cervical  rib,  it  may  occasionally  give  rise  to  a 
pulsating  tumor  simulating  an  aneurysm.  There  is  an  absence,  however, 
of  the  expansile  pulsation  characteristic  of  aneurysms  in  general,  and 
a  cervical  rib  producing  such  abnormal  pulsation  of  the  subclavian 
artery  occurs  at  an  earher  period  of  life  than  do  non-traumatic  aneurysms. 
A  skiagraph  will  confirm  the  suspicion  that  the  pulsating  tumor  is 
simply  the  subclavian  artery  stretched  over  the  end  of  a  cervical  rib. 
The  effects  on  the  arteries  vary  from  weakness  of  the  radial  pulse  to 
cyanosis.  In  extreme  cases  there  is  thrombosis  of  the  peripheral 
vessels,  resulting  in  gangrene.  The  nerve-pressure  symptoms  vary 
from  neuralgic  pain,  situated  in  one  of  the  branches  of  the  brachial 
plexus,  simulating  at  times  a  neuritis,  to  paresthesias  and  pareses  of 
the  muscles  of  the  arm. 


Fig.  90. — Dissection  of  a  Case  of  Cervical  Rib. 
7,  Seventh  cervical  vertebra;    i,  first  dorsal  vertebra;    2,  second  dorsal  vertebra.     On  the  right  side  ob- 
serve the  large  cervical  rib  arising  from  the  seventh  cervical  vertebra  close  to  its  junction  with  the  first  dorsal. 
On  the  left  side  observe  a  shorter  cervical  rib  (Schultze). 

The  diagnosis  can  be  easily  made  by  (a)  the  palpation  of  the  bony 
tumor  in  the  neck,  (b)  by  disturbances  of  circulation,  and  (c)  pressure 
symptoms  upon  the  brachial  plexus.  The  cervical  rib  may  vary  from 
a  short  projection  an  inch  long  to  one  extending  to  the  first  rib.  It 
must  be  differentiated. chiefly  from  exostoses  of  the  spine.  These  cause 
less  pressure  on  the  subclavian  artery,  but  more  on  the  vein,  causing 
edema  of  the  arm.  The  condition  must  also  be  differentiated  from  tuber- 
cular lymph-nodes  in  the  posterior  triangle  of  the  neck.  These  nodes  are 
never  as  hard  as  the  cervical  rib,  nor  arc  they  ever  attached  to  the  spine. 
Similar  nodes  are  also  to  be  found  in  the  upper  portions  of  the  neck.  A 
third  condition  from  which  a  cervical  rib  must  be  differentiated  is  that 
of  carcinomatous  enlargement  of  the  supracla\'icular  glands,  causing 
pressure  on  the  surrounding  structures.     These  may  be  very  firm  in 


ISO 


SURGICAL  AFFECTIOXS  OF  THE  XECK. 


consistency,  but  are  never  as  hard  as  a  cenical  rib,  and  there  is  usually 
a  histor}'  of  a  primar}'  growth  or  its  presence  at  the  time  of  examination 
in  the  territor}-  drained  by  these  nodes  (Fig.  74). 

Wry-neck,  or  Caput  Obstipum. — Wr}'-nec]^  produces  a  deformity 
wliich  can  be  readily  recognized  by  the  fact  that  the  head  is  inchned 
(Fig.  92)  toward  the  side  of  the  affected  muscles,  while  the  chin  is  directed 
toward  the  opposite  side,  and  there  is  always  some  rotation  of  the  head 
toward  the  opposite  side.  The  chief  point  of  surgical  interest  is  to 
determine  (a)  whether  the  condition  is  of  acute  or  chronic  nature,  or  (b) 


Fig.  91. — X-RAY  OF  a  Case  of  CER\acAL  Rib. 
The  rib  itself  has  been  outlined  in  black. 


whether  it  is  s}Tiiptomatic  or  congenital  in  origin.  Of  the  acute  causes 
wliich  may  produce  it  the  most  frequent  is  muscular  rheumatism. 
This  form  can  be  recognized  by  its  sudden  appearance,  the  absence  of 
any  swelling  or  tenderness  along  the  muscle,  with  considerable  pain  on 
movement,  and  the  histor}-  of  its  having  appeared  quite  acutely.  Its 
form  disappears  rapidly  after  antirheumatic  treatment.  A  second 
variety  of  acute  wr}--ncck  is  that  accompanying  infection  of  the  deep 
cer\dcal  lymph-nodes  (Fig.  92).  This  form  is  always  accompanied  by 
a  swelling  along  the  anterior  or  posterior  borders  of  the  muscle  and 
there  is  considerable  pain  upon  movement.     The  neck  is  held  quite 


CONGENITAL    AND    ACQUIRED    MALFORMATIONS. 


151 


rigid  in  the  typical  wry-neck  position.  Unless  this  swelHng  be  correctly 
interpreted  as  due  to  infection,  the  rigid  position  of  the  neck  with 
rotation  of  the  head,  etc.,  may  cause  the  suppuration  to  be  overlooked. 
A  symptomatic  wry-neck  posture  is  at  times  assumed  by  patients  fol- 
lowing operations  for  extirpation  of  tubercular  lymph-nodes,  and  may 
continue  for  some  months.  A  fourth  variety  of  wrv'-neck  is  that  fol- 
lowing extensive  bums  or  other  cicatricial  processes  of  the  neck.  It  is 
often  called  the  dermatogenous  variety,  to  distinguish  it  from  the 
simple  or  rheumatic,  and  the  symptomatic  forms  just  referred  to.  There 
is  no  difficulty  in  distin- 
guishing this  form,  owing 
to  the  fact  that  there  is 
always  ample  evidence  of 
scar  tissue,  either  on  the 
surface  or  in  the  subcu- 
taneous structures.  A  fifth 
form  is  that  which  occurs  in 
children,  the  myogenic.  It 
is  due  to  rupture  of  and 
hematoma  formation  in  the 
sternocleidomastoid  mus- 
cle, and  is  known  as  the  con- 
genital form.  Congenital 
wr}'-neck  is  often  accom- 
panied by  a  scohosis  of  the 
cendcal  vertebrae,  the  con- 
vexity in  the  cendcal  region 
being  toward  the  side  op- 
posite to  that  upon  which 
the  wry-neck  is  situated.  It 
is  not  infrequently  associ- 
ated with  Hmitation  of  the  visual  field  and  facial  hemiatrophy.  A  sixth 
form  of  wr}^-neck  is  that  due  to  disease  of  the  cervical  vertebrae.  In  this 
there  are  neuralgic  pains  radiating  from  one  or  both  sides  of  the  verte- 
brae. There  is  also  pain  over  the  spine,  stiffness,  and  the  head  is  held  in 
the  typical  fixed  position. 

Wry-neck  may  also  occur  in  a  seventh  form  secondary  to  subluxation 
and  rotation  of  the  cervical  vertebras.  These  cases  always  have  a 
history  of  trauma  and  the  spine  is  held  rigid  without  any  of  the  pain 
characteristic  of  tubercular  processes,  and  the  .r-ray  may  at  times 
confirm  the  subluxation. 


Fig.  92. — Typical  Wry-neck  Position. 

Occurring  as  the  result  of  suppuration  of  the  deep  cervical 

lymph-nodes. 


152  SURGICAL   AFFECTIONS    OF   THE   NECK. 

An  eighth  form  of  wry-neck  which  may  at  times  call  for  surgical 
interference  is  that  in  which  there  is  a  frequently  recurring  spasm  of  the 
sternocleidomastoid  and  trapezius  muscles.  This  form  is  called  spas- 
modic wry-neck. 

INJURIES  OF  THE  NECK. 

Injuries  of  the  various  structures  of  the  neck  may  occur  as  the  result 
of  suicidal  attempts,  of  gunshot  or  stab  wounds,  or  of  fractures.  The 
injuries  to  the  veins,  arteries,  nerves,  and  thoracic  duct  occurring  as  the 
result  of  operation  do  not  differ  from  those  due  to  other  modes  of  injury 
and  will  not  be  considered  separately. 

Injuries  to  the  Arteries. — These  occur  most  often  as  the  result  of 
stab  or  gunshot  wounds  and  may  result  in  a  partial  or  complete  severing 
of  the  artery  or  in  the  formation  of  an  aneurysm.  The  result  of  injuries 
of  the  arteries  of  the  neck  is  either  (a)  immediate  death,  if  the  wound 
in  the  artery  communicates  with  the  wound  in  the  skin,  or  (b)  a  large 
swelling  forms  in  the  neck  in  the  immediate  vicinity  of  the  wounded 
artery,  due  to  the  escape  of  blood  into  the  cellular  tissue.  Again,  (c) 
death  may  occur  at  a  later  period  through  sloughing  of  the  wall  of  an 
artery  following  a  small  wound  of  its  wall,  with  resultant  secondary  hem- 
orrhage. 

The  diagnosis  of  injury  of  the  carotid  artery  may  be  made  from  the 
escape  of  bright  red  blood  in  large  quantities  through  the  external  wound 
or  the  formation  of  a  hematoma  beneath  the  skin.  There  is  no  tem- 
poral pulse  to  be  felt.  In  wounds  of  the  subclavian  arteries  the  same 
symptoms  of  tremendous  primary  hemorrhage  or  the  formation  of  a 
hematoma  may  be  present,  accompanied  by  the  absence  of  the  radial 
pulse  of  the  same  side. 

The  majority  of  cases  of  wounds  of  the  arteries  of  the  neck  are  not 
seen  immediately,  so  that  the  diagnosis  depends  upon  the  location  (a) 
of  the  subcutaneous  hematoma,  (b)  the  location  of  the  wound,  and  (c) 
the  fact  that  there  is  no  pulse  in  the  distal  arteries. 

The  vertebral  artery  is  sometimes  injured  through  gunshot  wounds 
passing  through  the  mouth  or  through  a  wound  entering  an  inch  below 
and  behind  the  mastoid.  At  times  the  symptoms  of  injury  of  an 
artery  may  have  been  so  slight  at  the  time  of  the .  accident  that  the 
swelling,  if  any  was  present,  is  overlooked,  and  the  patient  only  pre- 
sents himself  when  a  pulsating  tumor  has  appeared  as  the  result  of  the 
formation  of  a  traumatic  aneurysm. 

Traumatic  Aneurysms. — The  symptoms  of  both  traumatic  and 
spontaneous  aneurysms  of  the  neck  are  the  same.     In  the  former  there 


INJURIES    OF   THE   NECK.  I53 

is,  however,  the  history  of  an  injury,  usually  a  gunshot  or  stab  wound. 
The  aneurysm  may  involve  the  artery  alone  or  there  may  be  communica- 
tion between  the  artery  and  the  vein.  The  majority  of  traumatic  aneu- 
rysms of  the  neck  are  found  in  the  carotid  artery. 

The  diagnosis  can  be  made  by  finding  a  pulsating  tumor,  usually 
situated  close  to  the  bifurcation  of  the  common  carotid  artery,  in  which 
there  is  a  thrill  to  be  felt.  If  the  aneurysmal  tumor  is  compressed  be- 
tween the  index  finger  and  thumb,  one  can  feel  a  distinct  expansile 
pulsation.  Not  infrequently  the  diagnosis  is  aided  by  finding  symptoms 
(a)  of  compression  upon  the  trachea,  causing  more  or  less  dyspnea,  (b) 
upon  the  esophagus,  causing  difficulty  in  swallowing,  and  of  (c)  pres- 
sure upon  the  hypoglossal  or  recurrent  laryngeal  nerves,  causing  diffi- 
culty in  speech  and  hoarseness,  respectively.  There  may  also  be  symp- 
toms of  pressure  upon  the  nerves  of  the  brachial  plexus.  In  aneurysm 
of  the  external  carotid  the  tumor  is  situated  below  the  angle  of  the  jaw 
and  pushes  the  tonsil  inward.  At  this  point  an  aneurysm  may  be  sim- 
ulated by  a  lymph-node  lying  upon  the  external  carotid.  Under  these 
conditions  the  pulsation  is  only  marked  when  the  gland  is  pressed  against 
the  vessel  and  there  is  no  expansile  pulsation,  as  is  the  case  in  true 
aneurysm. 

Aneurysms  of  the  subclavian  artery  may  follow  gunshot  or  stab 
wounds  or  rarely  fractures  of  the  clavicle,  in  which  the  fragments  have 
penetrated  the  artery.  Most  often,  however,  aneurysms  of  this  vessel 
are  the  result  of  endarteritis.  The  aneurysms  of  the  first  part  of  the 
subclavian  artery  are  difficult  to  distinguish  from  those  of  the  common 
carotid  and  innominate  arteries,  if  on  the  right  side.  The  aneurysms 
of  the  third  part  of  the  subclavian  can  be  recognized  by  the  presence 
of  a  pulsating  tumor  just  above  the  clavicle,  with  the  thrill,  expansile 
pulsation,  and  bruit  so  characteristic  of  aneurysms  elsewhere. 

An  anreurysm  of  the  subclavian  artery  must  be  differentiated  from  the 
condition  referred  to  above,  viz.,  the  subclavian  artery  being  stretched 
across  a  cervical  rib  and  giving  rise  to  a  pulsating  swelling,  which  may 
resemble  an  aneurysm.  The  absence  of  expansile  pulsation  and  the  de- 
tection of  the  elongated  cervical  rib  serve  to  distinguish  these.  Subcla- 
vian aneurysms  may  also  be  distinguished  by  the  fact  that  they  are  much 
more  apt  to  give  rise  to  symptoms  of  pressure  on  the  nerves  of  the 
brachial  plexus,  causing  either  neuralgia  or  wcaloiess  of  the  affected 
muscles.  The  most  frequent  location  of  aneurysms  of  the  subclavian  is 
in  the  third  portion  of  the  artery,  situated  on  the  outer  side  of  the 
sternocleidomastoid  muscle. 

Arterio-venous  aneurysms  as  the  result  of  trauma  most  frequently 


154  SURGICAL   AFFECTIONS    OF   THE   XECK. 

involve  the  common  carotid  artery  and  internal  jugular  vein.  The 
tumor  is  usually  irregular  and  lirm,  and  it  may  be  diminished  but  not  en- 
tirely obliterated  by  pressure.  There  is  an  intense  murmur  and  very 
marked  thrill  present,  both  of  which  disappear  when  the  carotid  is  com- 
pressed just  above  the  clavicle. 

Injuries  of  the  Veins. — Injuries  of  the  deeper  veins,  such  as  the 
innominate  and  subclavian,  are  most  frequently  the  result  of  gunshot 
or  stab  v^'ounds.  Those  of  the  internal  jugular  and  of  the  superficial 
veins  of  the  neck,  which  pass  across  the  median  fine,  are  usually  the 
result  of  attempts  at  suicide. 

The  diagnosis  of  an  injur}'  of  a  vein  may  be  made  in  the  same  manner 
as  in  the  case  of  injury  of  an  arter}'.  In  the  case  of  wounds  of  a  larger 
vein  such  severe  hemorrhage  may  occur  as  to  cause  immediate  death. 
A  hematoma  may  form  beneath  the  skin  around  the  wound  in  the  vein, 
and  in  the  majority  of  cases  the  patient  is  seen  in  this  condition. 

In  wounds  of  the  smaller  veins  air  embolism  may  be  the  result. 
This  condition  is  recognized  from  the  presence  of  one  of  two  groups  of 
s}Tnptoms,  either  (a)  a  gurghng  sound  in  the  neighborhood  of  the  wound, 
followed  by  immediate  death,  or  (b)  the  onset  of  marked  dyspnea,  great 
anxiety,  rapid  and  weak  pulse,  coma,  and  death  within  five  to  ten  minutes. 

Wounds  of  the  veins  may  be  recognized,  as  was  just  mentioned, 
either  by  primary  symptoms,  such  as  the  escape  of  blood  externally, 
the  position  of  the  wound,  and  the  history  of  a  gunshot  or  stab  wound  or 
an  attempt  at  suicide,  or  it  may  be  recognized  by  the  formation  of  a 
hematoma  or  the  presence  of  symptoms  of  air  embohsm.  The  secon- 
dary efi'ects  of  wounds  of  the  veins  are  the  formation  of  an  arterio-venous 
aneurysm,  if  the  wound  in  the  vein  communicates  with  the  one  in  the 
artery. 

Another  late  result  of  injury  to  the  vein  is  a  secondary  hemorrhage 
occurring  from  erosion  of  the  vein. 

Injuries  of  the  Nerves  of  the  Neck. — Injuries  of  the  vagus  may 
occur  as  the  result  of  gunshot  or  stab  wounds  or  rarely  following  opera- 
tions. It  can  be  recognized  by  the  appearance  of  dyspnea  and  occas- 
ionally of  hoarseness  through  severing  of  the  recurrent  lar}Tigeal.  At 
times  the  injur}-  of  the  vagus  of  one  side  will  produce  no  s}Tiiptoms. 
The  injur}'  of  both  vagi  results  in  aspiration  pneumonia. 

Injuries  of  the  sympathetic  cause  dilation  of  the  pupil  on  the  side 
of  the  injury  if  above  the  superior  ganglion. 

Injuries  oj  the  phrenic  cause  paralysis  of  the  corresponding  half  of 
the  diaphragm.  Injuries  of  the  brachial  plexus  ma}'  occur  as  the  result 
of  violent  blows,  of  fractures  of  the  clavicle,  after  gunshot  wounds,  or  as 


INJURIES    OF   THE    NECK.  I55 

the  result  of  severe  traction  on  the  shoulders  during  birth.  This  last- 
named  form  may  appear  in  children  under  the  cHnical  picture  of  the 
Duchenne  form  of  paralysis  (Fig.  271).  In  this  condition  there  has 
been  laceration  of  the  lowermost  branches  of  the  brachial  plexus. 

A  diagnosis  of  injuries  of  the  brachial  plexus  may  be  made  from  the 
appearance  of  trophic  disturbances,  of  paralyses  with  or  without  painful 
contractures,  or  of  neuralgias  of  some  of  the  branches  of  the  plexus, 
following  the  injuries  just  referred  to. 

Injuries  oj  the  cervical  nerves  are  very  rare  and  usually  cause  only 
loss  of  sensation,  transitory  in  nature,  of  the  skin  of  the  neck. 

Injury  of  the  spinal  accessory  nerve  often  occurs  as  the  result  of 
operations  in  the  posterior  triangle  of  the  neck.  It  may  be  recognized 
by  the  inabihty  of  the  patient  to  raise  the  shoulder  on  the  side  of  the 
injury  (Fig.  11). 

Injuries  of  the  Thoracic  Duct.— This  most  often  follows  extir- 
pation of  tumors  or  of  lymph-nodes  in  the  posterior  triangle  of  the 
neck.  It  may  be  recognized  by  the  escape  of  a  thin,  milky  fluid  from 
the  wound,  and  may  involve  either  the  main  duct  itself  or  one  of  its 
branches.  If  it  has  persisted  for  some  time,  it  causes  considerable 
emaciation  and  weakness,  due  to  the  non-absorption  of  fat. 

Fractures  of  the  Hyoid  Bone. — These  occur  after  attempts  at 
strangulation  or  after  being  run  over.  It  may  be  diagnosed  by  the 
presence  of  swelling  over  the  hyoid,  by  severe  pain  referred  to  the 
same  region,  and  from  the  dyspnea.  Not  infrequently  there  is  also 
great  difficulty  in  speech  and  in  swallowing.  Hemorrhage  accom- 
panying coughing  spells  is  also  a  frequent  symptom. 

Fractures  of  the  Larynx. — These  occur  as  the  result  of  choking,  of 
gunshot  wounds,  and  of  attempts  at  suicide.  On  palpation  one  can 
find  a  deformity  due  to  a  dislocation  of  the  cartilages  of  the  larynx  and 
also  crepitus.  There  is  often  severe  cough  with  bloody  expectoration  and 
other  symptoms  referred  to  under  fractures  of  the  hyoid  bone.  One  can 
distinguish  it  from  a  fracture  of  the  hyoid,  however,  by  the  greater 
cyanosis  and  dyspnea.  One  can  often  feel  the  ends  of  the  bone  pro- 
jecting through  the  overlying  skin. 

Fractures  of  the  Trachea. — These  are  comparatively  rare.  They 
are  the  result  of  stab  or  gunshot  wounds  or  attempts  at  suicide.  They 
may  be  recognized  by  the  presence  of  symptoms  of  stenosis  of  the  air 
passa^ges,  such  as  stridor,  dyspnea,  asphyxia,  and  hoarseness.  Not 
infrequently  there  is  emphysema  of  the  subcutaneous  tissues.  In 
wounds  of  the  trachea  following  cut-throat,  there  is  often  suppuration  of 
the  surrounding  tissue  and  secondary  hemorrhage.     The  infection  may 


156  SURGICAL  AFFECTIONS  OF  THE  NECK. 

spread  to  the  mediastinum.  When  the  external  wound  is  large,  the  diag- 
nosis of  an  injury  of  the  trachea  is  easy.  When  it  is  small,  one  can  only 
suspect  it  from  the  presence  of  subcutaneous  emphysema  and  bloody 
expectoration.  If  the  wound  in  the  trachea  communicates  with  a  wound 
in  the  esophagus,  food  escapes  through  the  wound  in  the  trachea  and 
is  expectorated  by  the  patient. 

Cut-throat. — The  various  conditions  found  in  cases  of  cut-throat 
or  attempts  at  suicide  have  been  described  in  detail.  A  diagnosis  may 
be  made  by  considering  the  symptoms  of  injuries  of  the  air  passages, 
nerves,  arteries,  and  veins  just  spoken  of.  The  internal  jugular  or 
common  carotid  are  seldom,  if  ever,  injured.  The  typical  place  for 
the  wound  in  the  skin  and  deep  parts  is  at  the  level  of  and  through 
the  cricothyroid  membrane.  If  the  wound  passes  into  the  larynx,  it 
may  sever  the  epiglottis  and  open  the  pharynx.  At  this  level  the 
lingual  and  superior  thyroid  arteries  and  veins  and  superior  laryngeal 
nerve  may  be  injured.  If  the  wound  is  above  the  hyoid,  the  lingual 
and  facial  arteries  and  veins  may  be  severed,  and  the  tongue  may  fall 
back  upon  the  epiglottis,  causing  asphyxia.  If  the  wound  is  through  or 
below  the  thyroid  cartilage,  the  recurrent  laryngeal  may  be  severed,  the 
trachea  and  esophagus  cut  across,  and  there  may  be  marked  asphyxia 
from  entrance  of  blood  into  the  trachea.  The  late  complications  of 
wounds  at  this  latter  level  are  cellulitis,  mediastinitis,  pneumonia,  and 
fistulae  of  the  trachea. 


FOREIGN  BODIES  IN  THE  AIR  PASSAGES. 

The  diagnosis  of  foreign  bodies  in  the  larynx  must  be  made  from  the 
history  and  the  presence  of  symptoms  of  stenosis  or  irritation.  These 
latter  are  violent  coughing,  recurrent  attacks  of  suffocation,  cyanosis, 
hoarseness,  or  aphonia.  The  sputum  is  at  first  bloody  and  then  puru- 
lent. If  the  foreign  body  is  a  solid  one  it  may  act  as  a  ball- valve,  being 
drawn  downward  during  inspiration  and  pushed  up  during  expiration. 
The  symptoms  of  stenosis  are  in  general  most  marked  during  in- 
spiration. 

Foreign  Bodies  in  the  Trachea  or  Bronchi. — The  diagnosis 
depends  (a)  upon  the  history  (one  must  ascertain  how  the  foreign  body 
entered  the  air  passages)  and  (b)  upon  the  presence  of  certain  local 
symptoms.  These  latter  are  wheezing  sounds  in  the  bronchi,  accom- 
panied by  diminished  respiratory  movement  upon  the  side  on  which 
the  foreign  body  is  situated,  and  diminished  fremitus.  Often  there  is 
partial  or  entire  collapse  of  the  corresponding  lung. 


INFLAMMATORY   PROCESSES.  I57 

In  the  case  of  metallic  substances  an  x-ray  picture  will  often  show 
their  exact  location  (Fig.  93).  In  the  case  of  non-metallic  substances 
one  must  depend  upon  a  search  for  them  with  the  bronchoscope,  an 
instrument  devised  by  Killian, 


INFLAMMATORY  PROCESSES. 

Inflammatory  processes  in  the  neck  may  be  either  acute  or  chronic. 
The  majority  of  the  latter  are  tuberculous  or  actinomycotic  in  nature. 
The  tuberculous  form  will  be  taken  up  in  connection  with  inflammation 


Fig.  93. — X-RAY  OE  Safety  Pin  of  Medium  Size  in  Trachea  Removed  by  Tracheotomy  after 

Ineffectual  Attempts  to  Use  the  Killian  Bronchoscope. 

The  outlines  of  the  pin  have  been  strengthened  in  black. 

of  the  lymph-nodes.     Acute  inflammatory  processes  may  arise  in  the 
neck  in  four  different  ways : 

1.  Infection  of  wounds  of  the  skin  or  soft  parts. 

2.  Extension  from  infection  in  the  mouth,  or  from  the  arm,  or  thorax, 
or  spine. 

3.  Infection  of  the  lymph-nodes  (this  is  the  most  frecjuent  form). 

4.  Metastatic  (this  is  cjuite  rare). 

The  diagnosis  of  acute  infective  processes  of  the  neck  depends  upon 


158 


SURGICAL    AFFECTIONS    OF   THE    NECK. 


a  knowledge  of  the  applied  anatomy.     This  teaches  that  there  are  four 
places  in  which  infection  most  frequently  occurs,  as  follows : 

1.  In  the  submaxillary  region.  In  this  the  submaxillary  lymph- 
nodes  lying  within  the  pocket  of  deep  fascia  (Fig.  76)  in  which  the 
submaxillary  salivary  gland  is  contained  are  affected,  and  from  this 
focus  the  surrounding  tissue  is  invaded. 

2.  The  previsceral  form.  In  this  the  tissue  in  front  of  the  trachea 
and  esophagus  lying  beneath  the  deep  layer  of  the  deep  cervical  fascia 
is  involved. 

3.  The  connective  tissue  along  the  carotid  sheath.     Infection  occurs 

most   frequently  here 
from  the  lymph-nodes. 

4.  The  space  at  the 
lower  end  of  the  sterno- 
cleidomastoid and  just 
above  the  clavicle. 

I.  Infection  in  the 
Submaxillary  Region. 
— The  diagnosis  of  infec- 
tion of  the  submaxillary 
region  may  be  made  from 
the  presence  of  great 
swelling,  of  a  tense  infil- 
tration of  the  surround- 
ing tissues,  and  tender- 
ness. The  swelling  is 
accompanied  by  heat  and 
redness.  There  is  also 
dysphagia  or  difficulty  in 
swallowing  from  pressure 
on  the  esophagus  and 
dyspnea  in  the  more  extensive  cases  of  infection.  The  dyspnea,  owing 
to  pressure  on  the  larynx  and  trachea,  may  be  even  so  severe  as  to  cause 
edema  of  the  glottis  or  asphyxia. 

The  floor  of  the  mouth  is  swollen  and  the  tongue  is  elevated.  In 
severe  cases  ulceration  of  the  arteries,  rarely  of  the  veins,  or  a  phle- 
bitis of  the  internal  jugular  may  occur.  If  no  surgical  relief  is  given, 
suppuration  may  extend  to  the  mediastinum  along  the  previsceral  or 
carotid  sheath  spaces.  In  ordinary  cases  of  infection  in  this  region  the 
suppuration  is  simply  confined  to  the  lymph-nodes. 

2.  Previsceral  Suppuration. — The  majority  of   the  infections  of 


Fig.  94. — Mode  of  Extension  of  Infection  in  Deep  Cervical 
Fascia. 
ST,  Sternothyroid  and  hyoid  muscles;  S,  sternocleidomastoid 
muscle;  R  and  M,  deep  muscles  at  back  of  neck;  Tr,  trapezius 
muscle;  V,  body  of  cerwcal  vertebra;  C,  structures  of  carotid 
sheath;  E,  esophagus;  T,  thyroid  cartilage,  and  opening  of  larynx; 
VI,  connective  tissue  of  free  visceral  space  (the  black  shading 
shows  direction  in  which  pus  can  spread) ;  PV,  mode  of  spreading 
of  pus  in  prevertebral  layer. 


INFLAMMATORY   PROCESSES. 


159 


the  cellular  tissue  of  the  previsceral  space  (Fig.  94)  arise  from  the 
thyroid  gland,  or  as  extensions  from  suppuration  in  the  submaxillary 
or  carotid  sheath  spaces.  The  diagnosis  can  be  made  from  the  presence 
of  edema,  usually  of  a  tense  character,  of  redness,  pain  and  the  ordinary 
signs  of  infection,  such  as  temperature,  and,  in  the  severer  cases,  symp- 
toms of  sepsis.  There 
is  great  danger  of 
pressure  on  the  tra- 
chea and  esophagus, 
especially  on  the  form- 
er, and  of  extension  of 
the  suppuration  to  the 
anterior  mediastinum, 
with  which  this  pre- 
visceral space  com- 
municates. The  pres- 
ence of  this  extension 
to  the  mediastinal  con- 
nective tissue  can  be 
recognized  by  the  con- 
tinuance of  the  tem- 
perature and  evi- 
dences of  sepsis  after 
subsidence  of  the  in- 
flammatory disturb- 
ances in  the  previsceral 
space,  as  well  as  the 
extension  of  the  local 
inflammatory  signs  to 
the  suprasternal  fossa 
and  the  tissues  over 
the  sternum.  This 
condition  is  referred  to 
more  fully  in  the  chap- 
ter upon  the  thorax. 

3.  Suppuration  in  the  Carotid  Sheath  Space. — The  most  fre- 
quent sources  of  infection  of  this  space  arc  the  lymph-nodes  lying 
beneath  the  sternocleidomastoid  muscles  and  along  its  anterior  and 
posterior  borders.  These  suppurative  inflammations  of  the  lymph- 
nodes  are  always  secondary  to  a  primary  infective  jocus  in  the  ter- 
ritory   drained  by  them.      In   the  case  of  the  upper  internal  jugular 


Fig.  95. — Portals  of  Infection  and  the  most  Frequent  Nodes  In- 
volved IN  Tuberculosis  of  the  Cervical  Lymph-nodes. 
The  arrows  show  the  direction  of  the  efferent  lymph-vessels  leading 
from  the  various  portals  of  infection  toward  the  respective  nodes  which 
are  first  infected:  M,  Uppermost  node  of  internal  jugular  vein  which 
receives  the  infective  material  from  the  ear;  T,  tonsillar  gland  located  in 
angle  of  internal  jugular  and  anterior  jugular.  This  receives  the  lymph 
from  the  tonsil.  From  /  downward  are  to  be  seen  the  principal  lymph- 
nodes  of  the  neck  which  receive  the  lymph  from  the  head  and  face. 
These  are  the  internal  jugular  group  lying  beneath  the  sternocleido- 
mastoid muscle  in  close  relation  to  the  internal  jugular  vein  (F)  and  in 
direct  connection  with  the  lymph-nodes  of  the  posterior  triangle  of  the 
neck  (P) .  S,  Submaxillary  nodes.  These  lie  either  upon  or  within  the 
capsule  of  the  submaxillary  salivary  gland  and  receive  the  infective 
material  from  the  teeth  and  jaws,  but  may  be  infected  by  retrograde  cur- 
rents from  the  tonsillar  lymph-nodes.  C,  Two  nodes  are  shown  mth  their 
short  venous  branch  leading  into  the  internal  jugular. 


l6o  SURGICAL   AFFECTIONS    OF   THE   NECK. 

group  the  primary  focus  is  usually  to  be  found  in  the  pharynx.  It 
may,  however,  be  the  direct  result  of  extension  from  infection  of  the 
submaxillary  lymph-nodes.  In  the  lower  internal  jugular  group 
(Fig.  95)  the  infection  may  have  had  its  origin  in  the  skin  of  the  supra- 
clavicular fossa.  It  is  well  to  remember,  from  a  diagnostic  stand- 
point, that  the  primary  focus  in  every  form  of  suppurative  lymph-node 
infection  may  have  entirely  healed  and  the  presence  of  such  a  primary 
focus  be  forgotten  by  the  patient  when  he  is  examined.  In  the 
case  of  the  infective  cellular  inflammations  along  the  carotid  sheath, 
the  patient  presents  himself  with  a  swelling  most  marked  either  along 
the  anterior  or  posterior  border  of  the  sternocleidomastoid.  If  the 
infection  is  extensive  there  is  usually  a  wry-neck,  referred  to  on  page  151, 
edema  of  the  overlying  skin,  dyspnea,  and  dysphagia.  If  the  upper 
internal  jugular  set  is  affected,  the  swelhng  is  usually  between  the  angle 
of  the  jaw  and  the  sternocleidomastoid  muscle.  If  the  lower  set  is 
involved,  the  swelling  is  most  marked  at  the  posterior  border  of  the 
muscle  just  above  the  clavicle.  In  severe  cases  there  are  symptoms  of 
constitutional  sepsis,  such  as  high  temperature,  rapid  pulse,  a  high 
degree  of  dehrium,  and  great  prostration.  In  addition  there  may  be 
dyspnea  and  difiiculty  in  swallowing  through  pressure  on  the  trachea 
and  esophagus.  If  the  condition  is  not  relieved,  the  pus  will  either 
escape  to  the  surface  and  break  through  the  skin,  or  find  its  way  to  the 
anterior  mediastinum. 

Infection  of  the  Superficial  Structures  of  the  Neck. 

The  most  frequent  form  of  superficial  infection  which  occurs  in  the 
skin  of  the  neck  is  a  furuncle,  which  m.ay  occur  at  any  portion,  but 
especially  in  the  region  just  beneath  the  superior  curved  line  of  the 
occipital  bone,  that  is,  at  the  nape  of  the  neck.  The  area  involved 
may  be  extensive,  there  being  multiple  foci  of  the  suppuration.  The 
term  carbuncle  is  given  to  this  form  by  the  laity. 

The  diagnosis  of  this  condition  is  not  diflicult.  The  chief  point  to  be 
remembered,  however,  is  the  possibihty  of  the  infection  extending  to  the 
lymph-nodes  along  the  carotid  sheath  or  in  the  posterior  triangle  of  the 
neck,  referred  to  later.  This  infection  of  the  lymph-nodes  may  be  pres- 
ent quite  early  in  an  ordinary  furuncle,  as  a  nodular  enlargement  along 
the  borders  of  the  sternocleidomastoid  muscle.  This  nodule  will  fre- 
quently subside  as  soon  as  the  furuncle  has  healed.  In  other  cases 
two  or  three  weeks  after  heahng  of  the  furuncle,  these  deep  lymph- 
nodes  begin  to  enlarge  and  suppurate.  The  diagnosis  of  this  comph- 
cation  is  referred  to  later. 


.  INFLAMMATORY   PROCESSES.  l6l 

A  number  of  other  infective  inflammations  occur  in  the  neck,  whose 
recognition  is  of  great  importance. 

The  Woody  Phlegmon,  or  Phlegmon  Ligneux  of   Reclus. — 

This  occurs  either  in  the  lateral  or  anterior  regions  of  the  neck.  It  is 
characterized  by  a  very  chronic  course  and  involves  a  large  area  of  skin 
and  subcutaneous  tissue.  There  are  but  few  inflammatory  symptoms. 
The  skin  is  red  and  extremely  hard,  almost  woody  in  consistency, 
hence  the  term  woody  phlegmon.  Later  this  induration  becomes 
softer  and  there  is  pus  formation. 

Actinomycosis. — The  neck  is  more  frequently  affected  than  any 
other  portion  of  the  body,  after  the  jaw  and  teeth.  The  disease  usually 
arises  by  direct  extension  from  primary  foci  in  the  jaw  or  teeth.  It  can 
be  recognized  by  the  appearance  of  a  slowly  increasing,  painless  swell- 
ing in  the  submental  and  submaxillary  regions,  which  is  at  first  quite 
indurated,  but  soon  softens,  and  the  abscess  breaks,  leaving  a  sinus 
lined  with  flabby  granulation-tissue,  containing  the  characteristic  yel- 
lowish granules.  There  is  a  distinct  bluish  color  over  the  softer  areas. 
The  diagnosis  can  be  made  usually  (a)  from  the  history  of  the  occurrence 
of  similar  abscesses  around  the  jaw,  (b)  from  the  characteristic  tense 
infiltration  of  the  deeper  connective  tissue  of  the  neck,  with  abscess 
and  sinus  formation.  There  are  two  conditions  which  must  be  differ- 
entiated from  it.  The  first  is  tubercular  inflammation  of  the  lymph- 
nodes,  and  the  second,  tertiary  syphilitic  gummata.  The  former  can 
be  distinguished  from  the  fact  that  the  area  involved  by  actinomycosis 
is  larger  than  is  the  case  in  tuberculosis. 

Tuberculosis  is  usually  hmited  to  certain  definite  groups  of  lymph- 
nodes,  either  the  submental,  submaxillary,  or  deep  cervical,  which,  if 
they  break  down  and  form  sinuses,  differ  in  their  external  appear- 
ance from  actinomycosis.  The  tubercular  sinuses  have  undermined 
edges,  and  the  granulations,  although  flabby,  are  often  caseous  in 
appearance.  The  finding  of  the  actinomyccs  in  the  yellow  granules  of 
the  pus  will  confirm  the  diagnosis  of  actinomycosis.  There  is  often  a 
history  of  cattle  infected  with  the  disease,  which  the  patient  has  been 
taking  care  of.  From  tertiary  syphilitic  gummata  the  differentiation  is 
comparatively  easy.  These,  when  they  give  rise  to  ulceration  of  the 
skin,  have  indurated  edges  and  the  ulcer  is  usually  extensive.  The 
edges  are  sharp  or  steep  and  are  not  undermined.  There  is  also  a 
history  of  an  initial  lesion  or  the  evidences  of  the  disease  elsewhere. 


l62 


SURGICAL   AFFECTIONS    OF   THE   NECK. 


Affections  of  the  Lymph-nodes  of  the  Neck. 

These  may  be  either  primary  or  secondary,  acute  or  chronic.  The 
lymph-nodes  of  the  neck,  as  elsewhere  in  the  body,  act  as  filters  for 
infective  agents  brought  to  them  from  the  territory  which  they  drain. 
If  one  bears  this  in  mind,  the  diagnosis  of  affections  of  the  lymph-nodes 
in  any  portion  of  the  body  becomes  much  simpler  and  is  a  valuable 
diagnostic  aid  (Fig  95). 

Acute  Inflammation. — With  the  exception  of  the  quite  rare  acute 


Fig.  96. 

Bilateral   enlargement   of    the   submaxillary   and 

parotid  lymph-nodes  in  Hodgkin's  disease. 


Fig.  97. — Side  View  of  Patient  with  Hodgkin's 
Disease. 
Observe     the     large     submaxillary     glandular 
swelling  as  well  as  the  relatively  large  size  of  the  nodes 
lying  over  the  parotid  salivary  gland. 


and  subacute  forms  of  tubercular  inflammations  of  the  cervical  lymph- 
nodes,  all  of  the  acute  infective  processes  belong  to  one  of  two  groups. 

1.  Acute  infection  of  the  submaxillary  and  deep  cervical  or  internal 
jugular  lymph-nodes.  These  are  almost  invariably  secondary  to  infec- 
tions of  the  tonsils,  either  the  faucial  or  pharyngeal  tonsil,  or  due  to 
carious  teeth. 

2.  Those  of  the  deep  cervical  chain.  These  are  either  secondary  to 
furuncles  in  the  skin  or  to  infective  processes  of  the  pharynx.     The 


INFLAMMATORY   PROCESSES. 


163 


diagnosis  of  botli  of  these  forms  is  comparatively  easy  and  has  been  re- 
ferred to  on  pages  158  and  159. 

Chronic  Enlargements  of  the  Cervical    Lymph-nodes. — The 

cervical  lymph-nodes  are  more  frequently  enlarged  than  those  of  any 
other  portion  of  the  body  and  in  the  majority  of  cases  this  is  due  to  the 
tubercle  bacillus.     The  different  forms  of  chronic  enlargements  of  the 
lymph-nodes  of  the  neck  belong  to  one  of  the  following  groups: 
(a)  Simple  hyperplastic  lymph-node  inflammation. 


Fig.  98. — Anterior   View   of   Case   of   Marked 
Hodgkin's  Disease. 


Fig.  99. — View  of  Case  of  Hodgkin's  Disease. 
Showing  both  cervical  and  axillary  node  enlargement. 


(&)  Tuberculosis  of  the  cervical  lymph-nodes : 
.1.  The  acute  progressive  form. 

2.  The  subacute  or  pseudo-leukemic  form. 

3.  The  chronic  form. - 

(c)  Pseudo-leukemia  or  Hodgkin's  disease. 
{d)  Lymphatic  leukemia. 
(e)  Lymphosarcoma. 

(/)  Secondary  carcinomatous  lymph-nodes. 
is)  Syphihs  of  the  cervical  lymph-nodes. 

In  examining  any  case  in  which  by  a  process  of  exclusion  of  other 
forms  of  tumors  of  the  neck  (see  page  172)  one  has  arrived  at  the  con- 


i64 


SURGICAL   AFFECTIONS    OF   THE    NECK. 


Fig.  ioo. — Primary  Branchiogexic  Carcinoma  of  Neck 

(anterior  view). 

Observe  the  involvement  of  the  skin  at  a  point  slightly  distant 

from  the  original  focus. 


clusioQ  that  the  enlargement 
is  due  to  the  ]}TT!ph-nodes, 
the  first  question  to  be  con- 
sidered is,  are  tliese  lymph- 
nodes  primary  or  secondary 
in  nature? 

The  majority  oj  all  en- 
largements of  the  lymph- 
nodes  oj  the  neck  are  secon- 
dary in  nature,  only  a  small 
percentage  being  primary. 
In  this  manner  one  can  first 
exclude,  in  any  given  case, 
the  so-called  primary  forms, 
which  are  as  follows: 

{a)  Lymphatic  leukemia. 

(b)  I/ymphosarcoma. 

(c)  Pseudo-leukemia 
(Hodgkin's  disease),  or  ma- 
lignant lymphoma. 

The  chief  characteristics  of  these  primary  enlargements  are  the 
following : 

Lymphatic  Leukemia . — In  this 
disease  the  enlargement  of  the 
lymph- nodes  is  usually  quite  ex- 
tensive, being  distributed  over 
both  sides  of  the  neck,  as  w^ell  as 
over  the  axillary  and  inguinal 
regions.  The  glands  themselves 
are  soft  and  quite  movable. 
There  is  no  tendency  to  any  ad- 
hesion of  the  individual  glands 
to  each  other  or  to  the  surround- 
ing tissue.  There  is  also  no  ten- 
dency to  softening,  as  is  the  case 
w^ith  tuberculous  enlargements. 
The  examination  of  the  blood 
will  show  the  presence  of  a  very 
large  number  of  lymphocytes,  so  yig.  ioi.-lateral  view  of  a  case  of  br.^nchio- 
that  the  proportion  of  white  to  ^-^^'^  carcinoma  of  the  neck; 

,  ,  .  .        ^    .      .  Note  the  serpentine  raised  edges  and  the  ulcerating 

red  corpuscles,  mstead  oi  bemg  centers. 


INFLAMMATORY   PROCESSES. 


165 


one  to  five  hundred,  is  sometimes  one  to  two.  The  disease  may  occa- 
sionally begin  in  a  very  acute  manner  with  fever,  etc.  (acute  lymphatic 
leukemia). 

Lymphosarcoma. — This  disease  usually  begins  in  one  node,  which 
enlarges  rapidly.     The  growth  soon  infiltrates  the  surrounding  tissue 


Fig.  102. — Method  of  Examination  for  Enlargement  of  the  Deep  Cervical  Lymph-nodes  Along  the 
Borders  of  the  Sternocleidomastoid  Muscle. 
Both  patient  and  examiner  should  be  seated,  the  latter  sitting  upon  the  right  side  of  the  patient,  when  the 
size  and  number  of  the  nodes  of  the  left  side  is  to  be  determined  and  vice  versa  in  the  case  of  the  right  side. 
The  patient's  head  should  be  grasped  with  one  hand,  while  the  other  hand  is  inserted  along  the  anterior  border 
of  the  stemomastoid,  the  muscles  of  the  neck  being  relaxed  by  bringing  the  patient's  chin  down  somewhat 
toward  the  sternum. 


and  there  is  early  ulceration  of  the  skin  over  the  tumor.  Very  early 
in  the  disease  there  are  evidences  of  metastases  in  distant  parts  of  the 
body. 

The  tumor  is  always  movable  on  the  deeper  structures,  so  that  it 
can  be  distinguished  from  sarcomata  arising  from  these.  The  diag- 
nostic points  are  the  rapid  growth  of  the  tumor  and  its  firm  consistency. 


i66 


SURGICAL  AFFECTIONS  OF  THE  NECK. 


It  is  much  harder  than  tuberculous  lymph-nodes  and  has  a  marked 
tendency  to  ulceration. 

Pseudo-leukemia,  or  Hodgkin^s  Disease. — This  may  occasionally 
appear  in  an  acute  form,  but  more  frequently  in  a  chronic.  The  nodes 
become  enlarged  at  first  on  one  side  of  the  neck  and  soon  afterward 
those  of  the  other  side  are  affected.  This  is  accompanied  by  enlarge- 
ment of  the  axillary  and  inguinal  lymph-nodes,  and  later  of  the  bron- 
chial, mediastinal,  and  mesenteric.     This  form  of  enlargement  of  the 

lymph-nodes  is  progres- 
sive in  character.  It  af- 
fects the  lymph-nodes  all 
over  the  body,  usually 
more  or  less  symmetri- 
cally. There  is  no  ten- 
dency to  suppuration  al- 
though the  lymph-nodes 
themselves  are  soft.  They 
are  easily  movable  in  the 
surrounding  tissue,  and 
do  not  become  adherent 
to  the  skin,  which  is  mov- 
able over  it.  Often  dif- 
ferent nodes  of  one  group 
become  adherent  to  each 
other,  forming  quite  large 
tumors,  which  can  be 
recognized  as  lymph- 
nodes  by  their  nodulated, 
soft  consistency  and  their 
location  along  the  usual 
area  of  distribution  of 
the  cervical  lymph-nodes.  The  enlargement  is  painless  as  a  rule  and 
not  accompanied  by  temperature. 

The  diagnosis  of  this  form  can  be  made  from  (a)  the  symmetrical 
distribution  of  the  lymph-node  enlargement,  (b)  the  absence  of  any  ten- 
dency to  break  down,  and  (c)  the  progressive  involvement  of  lymph- 
nodes  all  over  the  body,  which  later  in  the  disease  cause  pressure 
symptoms. 

These  are  dyspnea  through  pressure  on  the  trachea,  or  dysphagia 
through  pressure  on  the  esophagus,  or,  in  the  abdomen,  ascites.  There 
is  usually  accompanying  anemia  and  cachexia.     There  are  no  changes  in 


Fig. 103. 


-Method  or  Determining  Fluctuation  in  Suppu- 
rating Lymph-nodes  of  the  Neck. 


INFLAMMATORY   PROCESSES. 


167 


the  blood  except  a  progressive  anemia,  thus  serving  to  distinguish  it 
from  lymphatic  leukemia.  There  is  great  difficulty  in  differentiating  a 
true  case  of  pseudo-leukemia  or  maHgnant  lymphoma  (Hodgkin's  dis- 
ease) from  the  pseudo-leukemic  form  of  tuberculous  inflammation  of 
the  lymph -nodes.     This  is  referred  to  on  page  171. 

If,  in  a  case  of  enlargement  of  the  lymph-nodes  of  the  neck,  one  has 
excluded  these  three 
primary  forms  of 
lymph-node  enlarge- 
ment, the  diagnosis 
must  be  further  made 
by  excluding  one  after 
the  other  of  the  follow- 
ing secondary  forms : 

(a)  Carcinoma- 
tous. 

(b)  Syphilitic. 

(c)  Tubercular. 

(d)  Simple  hyper- 
plastic. 

(a)  Carcinoma- 
tous.— These  appear 
in  the  neck  as  an  early 
manifestation  of  the 
presence  of  a  carcin- 
oma in  the  respective 
territories  drained  by 
the  cervical  lymph- 
nodes  (Fig.  95).  The 
primary  ,carcinoma 
may  be  comparatively 
easily  found,  so  that 
the  diagnosis  is  not 
difficult.      But    there 

are  cases  where  the  secondary  lymph-node  involvement  is  the  first 
evidence  that  a  carcinoma  exists  and  this  latter  may  be  quite  small. 
The  characteristics  of  carcinomatous  lymph-nodes  are  that  they  are 
extremely  hard,  the  skin  is  movable  over  them,  and  they  are  easily 
'  movable  upon  the  underlying  and  surrounding  structures.  The  en- 
largement may  be  confined  to  the  lymph-nodes  of  one  region  (Fig.  75), 


Fig.  104. — The  Relation  of  Tdberculous  Lymph-nodes  of  the 
Neck  to  the  Sternocleidomastoid  Muscle. 
I,  Several  large  nodes  which  are  fused  together,  lying  in  front  of 
the  muscle,  extending  as  far  forward  as  the  angle  of  the  jaw,  the  black 
area  at  the  lower  level  of  this  mass  indicates  a  sinus  covered  with 
tuberculous  granulation-tissue;  2,  a  similar  mass  situated  in  the  upper 
portion  of  the  posterior  cervical  or  occipital  triangle,  between  the 
upper  ends  of  the  sternocleidomastoid  and  trapezius  muscles;  the 
sternocleidomastoid  muscle  usually  lies  superficial  to  such  glandular 
masses,  the  latter  being  adherent  to  the  deep  vessels;  3,  mass  of  nodes 
at  lower  portion  of  posterior  cervical  triangle  (subclavian  triangle); 
the  black  area  at  the  center  of  this  mass  is  a  sinus  similar  to  the  one  in 
relation  to  the  other  nodes;  4,  outlines  of  sternocleidomastoid  muscle. 


i68 


SURGICAL  AFFECTIONS  OF  THE  NECK. 


for  example,  submaxillary  or  submental,  or  may  be  present  on  both  sides 
of  the  neck. 

The  diagnosis  can  be  made  (a)  from  the  extremely  firm  consistency 
of  the  tumors  situated  in  places  where  the  various  lymph-nodes  are 
normally  found,  (&)  the  age— usually  above  forty,  (c)  presence  of 
cachexia,  (d)  negative  findings  in  the  blood,  and  (e)  the  discovery  of  the 
primary  focus.  In  the  later  stages,  when  ulceration  of  the  overlying 
skin  has  taken  place,  the  case  may  impress  one  as  a  primary  carcinoma 

of  the  neck,  but  these 
are  extremely  rare,  and 
are  always  due  to  a 
branchiogenic  carcin- 
oma (Fig.  loo).  In 
some  cases  one  is  justi- 
fied in  making  a  diag- 
nosis of  a  primary 
a;rowth  if  a  careful 
search  has  failed  to 
reveal  any  other  pri- 
mary focus.  The  only 
conditions  which  could 
be  confused  with  car- 
cinomatous lymph- 
nodes  are  those  cases 
of  primary  branchio- 
genic carcinoma  which 
have  not  broken 
through  the  skin. 
These  are  always 
deeply  situated  along 
the  middle  of  the 
s  t  e  rn  o  cleidomastoid, 
but  differ  from  secondary  carcinomatous  lymph-nodes  by  being  firmly 
attached  to  the  deeper  structures  of  the  neck.  In  every  case  of  suspected 
carcinomatous  enlargement,  one  should  examine  systematically  the 
various  structures  of  the  head  where  a  primary  carcinoma  occurs,  not 
omitting  a  search  in  the  sinus  pyriformis,  anterior  wall  of  the  phar>Tix, 
and  interior  of  the  larynx. 

(b)  Syphilitic  Lymph-node  Enlargement. — These  occur  in  the  primary 
stage,  secondary  to  a  chancre  of  the  hps,  tongue  (Fig.  8i),  or  other  forms 
of  extragenital  infection  of  the  head  or  neck.     The  finding  of  the  primary 


Fig.  105. — Tuberculous  Lymph-nodes  of  the  Neck. 
Observe  the  prominence  just  below  and  behind  the  angle  of  the 
jaw,  to  which  the  arrow  points.  The  black  area  at  the  lower  edge  of 
the  swelling  and  a  similar  area  at  the  lower  portion  of  the  neck  are 
two  sinuses  hned  with  yellowish  granulation-tissue,  characteristic  of 
tuberculosis. 


INFLAMMATORY   PROCESSES. 


169 


focus  and  its  recognition  as  syphilitic  in  nature  will  render  the  diagnosis 
easy.  In  the  secondary  stage  of  syphihs  there  is  occasional  enlarge- 
ment of  a  few  of  the  lymph-nodes  of  the  neck.  The  presence  of  secon- 
dary eruptions  on  the  skin  or  mucous  membrane  often  accompanies  this 
condition  and  in  their  absence  the  only  forms  which  need  to  be  differ- 
entiated from  them  in  this  stage  are  simple  hyperplastic  lymph-nodes, 
which  are  usually  much  firmer  and  smaller.  In  the  tertiary  stage  one 
will  encounter  quite  rarely,  enlargement  of  the  deep  cervical  or  internal 
jugular  lymph-nodes, 
which  cannot  be  dis- 
tinguished, in  the  ab- 
sence of  a  history  of 
syphilis,  from  simple 
hyperplastic  or  tuber- 
cular nodes  until  ulcer- 
ation of  the  skin  has 
occurred.  At  such  a 
time  the  aspect  of  the 
ulcer  will  clear  up  any 
doubt  about  the  diag- 
nosis. It  has  the  typi- 
cal appearance  of  the 
syphilitic  processes  in 
the  tertiary  stage.  The 
edges  are  somewhat 
copper- colored  and  in- 
durated, but  not  as 
much  so  as  in  the  case 
of  a  carcinoma.  They 
show  the  characteris- 
tic steep  edges  of 
a  syphihtic  ulcer  and 

the  ulceration  is  always  more  extensive  than  in  the  case  of  tuberculosis. 
In  doubtful  cases  the  administration  of  iodid  of  potassium  will  cause  a 
speedy  healing  of  the  enlarged  gland  or  ulcer,  as  the  case  may  be. 

(c)  Tuberculous  Lymph-node  Enlargement. — As  a  rule,  tuberculosis  of 
the  cervical  lymph-nodes  appears  in  a  chronic  form,  with  the  following 
clini-cal  picture:  In  the  submaxillary  region  or  along  the  anterior  or 
posterior  borders  of  the  sternocleidomastoid,  or  in  the  posterior  triangle 
of  the  neck,  one  linds  slowly  enlarging,  soft,  non-adherent  tumors,  which 
soon  coalesce,  becoming  adherent  to  each  other,  and  to  the  surrounding 


Fig.  106. — Enlargement   of   the   Submental  Lymph-nodes,  the 
Result  of  Tuberculous  Lymphadenitis. 


SURGICAL   AFFECTIONS    OF   THE    NECK. 


tissues  and  skin.  This  adhesion  of  the  skin  may  not  take  place  until 
the  enlargement  has  become  quite  advanced.  At  an  early  period  there 
is  softening  and  pus  formation  and  the  caseous  gland  becomes  adherent 
to  the  surface  (Fig.  103),  iluctuation  becoming  distinct.  Unless  surgical 
measures  are  undertaken  at  this  stage,  the  pus  discharges  through  the 
skin  and  a  tubercular  sinus  forms.  The  diagnostic  points  of  the  chronic 
form  of  tuberculous  lymph-nodes  are  the  slowly-forming,  soft  tumors, 
which  show  a  great  tendency  to  softening  and  pus  formation.  There 
are  no  evidences  of  inflammation  of  the  overlying  skin  until  the  node 

becomes  adherent  to  it, 
when  the  skin  becomes  of 
a  bluish  color,  and  there  is 
quite  distinct  fluctuation. 
Before  making  a  positive 
diagnosis,  however,  of  tu- 
berculous infection,  a  care- 
ful search  should  be  made 
for  primary  foci  such  as  a 
pharyngeal  tonsil  (adenoid 
vegetations) ,  or  of  enlarged 
caseous  tonsils,  or  of  a 
chronic  middle  ear  sup- 
puration. These  three 
are  the  most  frequent  in- 
fection atria  for  tubercu- 
lous cervical  lymph- nodes. 
The  less  frequent  ones  are 
the  teeth  and  tongue.  If 
a  sinus  has  formed,  it  can 
be  recognized  as  tubercu- 
lous by  its  bluish  under- 
mined edges  and  the  presence  of  flabby,  caseous  granulations  Hning 
the  opening  in  the  skin.  This  form  of  lymph-node  enlargement  occurs 
most  frequently  during  the  first  twenty  years  of  Hfe,  but  must  be  thought 
of  in  examining  any  case,  even  at  a  later  period.  The  acute  form  is 
fortunately  quite  rare.  The  clinical  picture  is  that  of  a  rapid  enlarge- 
ment of  the  submaxillary  and  deep  cervical  lymph-nodes,  accompanied 
by  a  high  continued  fever,  with  morning  remissions  in  some  cases.  In 
others  there  is  only  a  moderate  degree  of  fever.  It  can  be  differentiated 
from  the  other  acute  forms  of  infective  lymph-node  inflammation  by  the 
absence  of   a  primary  pus  focus  in  the  skin  or  mucous  membrane. 


Fig.  107. — Distribution  of  Enlarged  Lymph-nodes  in  a 
Case  of  the  Pseudo-leukemic  Form  of  .Tdbeecu- 
LOirs  Lymph-nodes. 


INFLAMMATORY   PROCESSES. 


171 


There  is  also  less  pain  and  swelKng  of  the  surrounding  structures.  The 
nodes  soon  become  adherent  to  each  other,  pus  formation  occurs,  and 
the  course  of  the  disease,  such  as  sinus  formation  and  discharge  through 
the  skin,  is  the  same  as  in  the  chronic  form.  During  epidemics  of  so- 
called  glandular  fever,  more  properly  called  Pfeiffer's  disease,  such 
cases  of  acute  tuberculous  cervical  lymph-nodes  are  apt  to  be  interpreted 
as  this  disease,  and  vice  versa.  Pfeiffer's  disease  is  usually  accompanied 
by  more  constitutionalsymptoms,suchasa  rapid  pulse  and  higher  temper- 
atures, there  is  httle  tendency 
to  breaking  down  of  the  glands, 
and  they  do  not  become  adher- 
ent to  each  other.  There  is  not 
infrequently  the  history  of  an 
epidemic  of  this  disease. 

The  pseudo-leukemic  or 
subacute  form  of  tuberculous 
lymph-node  enlargement  greatly 
resembles  (Fig.  107)  true 
pseudo-leukemia  or  malignant 
lymphoma.  It  involves  not 
infrequently  lymph-nodes  on 
both  sides  of  the  neck  as  well  as 
those  of  the  axillary  and  ingui- 
nal regions,  but  there  is  not 
the  same  tendency  to  progres- 
sive enlargement  as  is  the  case 
with  true  pseudo-leukemia. 
The  only  crucial  test  in  moder- 
ately advanced  cases  is  by  the 
excision  of  one  of  the  nodes, 
and    its     inoculation    into    a 

guinea-pig.  This  pseudo-leukemic  form  of  tuberculous  lymph-node  in- 
flammation has  been  fully  described  by  Fischer.  Its  clinical  recognition 
is  of  considerable  importance,  as  many  such  cases  are  erroneously  diag- 
nosed as  true  pseudo-leukemia:  The  characteristic  difference  between 
the  two  is  the  less  marked  enlargement  of  the  lymph-nodes  in  tubercu- 
losis, the  fact  that  the  mediastinal  and  abdominal  nodes  are  never  in- 
volved, and  that  there  are  no  pressure  symptoms,  anemia,  or  cachexia. 

The  differentiation  of  chronic  tuberculous  l3^mph-nodes  must  be 
made  (a)  from  syphihtic,  (b)  from  mahgnant  (most  often  lymphosarcoma, 
rarely  carcinoma),   (c)  from  pseudo-leukemic,  and  (d)  from   leukemic 


Fig.  108. — Anterior  View  of  Location  of  Various 
Forms  of  Tumors  of  the  Neck  (diagrammatic). 
M,  Dermoid  cj'sts  and  enlargements  of  the  submental 
nodes;  5,  tumors  and  inflammatory  enlargements  of  the 
submaxillary  lymph-nodes  and  salivary  glands;  B,  most 
frequent  location  of  branchial  cysts  and  parathyroids; 
C,  enlargements  of  the  deep  cervical  lymph-nodes;  T, 
tumors  of  the  thryoid;  CR,  cervical  rib;  A'',  subclavian 
aneurysms;    R.  retrosternal  goiter. 


172  SURGICAL  AFFECTIONS  OF  THE  NECK, 

enlargement.     This    differentiation    has    been    referred   to   under   the 
separate  groups. 

Simple  Hyperplastic  Lymph-nodes. — This  last  form  of  lymph-node 
enlargement  is  characterized  by  the  presence  of  painless  soft  nodules, 
in  the  usual  location  of  the  cervical  lymph-nodes.  Rarely  they  are 
firmer  in  consistency.  The  diagnosis  can  be  made  from  the  fact  that 
they  are  painless,  show  no  tendency  to  breaking  down,  are  freely  mov- 
able, not  matted  together,  and  cause  no  symptoms. 


TUMORS  OF  THE  NECK. 
Examination. — In  examining  a  tumor  of  the  neck  for  diagnostic 
purposes  one  should  conduct  the  examination  in  a  systematic  manner 
as  follows: 

1.  The  history  of  the  case. 

(a)  The  age  of  the  patient. 

(&)  When  did  the  tumor  appear  ?     Was  it  present  at  birth  or 

shortly   after?     Did  it  appear  at  infancy,  at  or  near 

puberty,  middle  or  old  age? 
(c)   Has  the  growth  of  the  tumor  been  rapid  or  slow? 
{d)  Where  did  the  tumor  first  show  itself? 
(e)   History  of  trauma,  etc. 
(/)   Is  the  tumor  subject  to  attacks  of  inflammation?     (This 

is  frequently  the  case  in  lymphangiomata.) 

2.  Physical  examination. 
A.  Inspection: 

I.  Location  of  the  tumor.  This  is  easy  to  note  unless  the  tumor 
spreads  over  both  sides  of  the  neck.  The  various  regions 
in  which  the  tumors  of  the  neck  occur  most  frequently, 
are : 

(a)  Submaxillary  and  submental  regions  (lymph-nodes,  tumors 
of  the  jaw,  dermoids  of  the  floor  of  the  mouth,  bran- 
chial cysts,  Hpomata). 

(&)  Along  the  course  of  the  trachea  and  the  lar}Tix  (goiter, 
thyroglossal  cysts,  thyrohyoid  bursse). 

(c)  Along  the  carotid  sheath  (lymph-nodes,  sarcomata  (deep), 
aneurysms,  angiomata,  branchial  cysts  and  branchio- 
genic  carcinomata,  pressure  diverticula  of  the  esopha- 
gus). 

{d)  Supraclavicular  fossa  (lymph-nodes,  aneurysms,  ostcomata, 
cervical  rib). 


TUMORS    OF   THE    NECK. 


173 


(e)   Suprasternal  fossa  (retrosternal  goiter  and  aneur>'sms). 
II.  Consistency  of  the  skin  over  the  tumor. 

(a)  Whether  it  is  bluish  or  reddened,  whether  stretched  or  ad- 
herent, whether  ulcerated  or  marked  by  dilated  veins. 

B.  Palpation: 

(a)  The  consistency  of  the  tumor.     Whether  it  is  hard  or  soft, 

semi-fluctuating,  or  cystic. 

(b)  Whether  it  is  adherent  or  movable  to  the  underlying  tissues 

and  skin  covering  it. 

(c)  Its  relation  to  the  trachea  as  determined  by  the  swallowing 

test  (see  page 
185) — a  symp- 
tom frequently 
pathognomonic 
of  goiters. 

(d)  Pressure    symp- 

toms on  the  tra- 
chea, vessels,  or 
nerves,  and  up- 
on the  esopha- 
gus. 

(e)  Examination     for 

the  presence  of 
expansile  pul- 
sation and  thrill 
— a  sign  charac- 
teristic of  an- 
eurysm. 
(/)  Conchtion  of  sur- 
face of  tumor, 
whether  smooth 


Fig.  log— Lateral  View  of  Most  Frequent  Situ- 
ations OF  Tumors  of  the  Neck. 
P,  Parotid  tumors;  5,  submaxillary  neoplasms  and 
lymph-node  enlargements;  T,  enlargements  of  lateral 
lobes  of  thyroid;  C,  the  many  black  areas  correspond  to 
the  locations  of  the  larger  of  the  deep  cervical  nodes 
under  the  sternocleidomastoid  muscle  and  in  front 
of  and  behind  it;  A ,  lymph-nodes  in  posterior  triangle 
of  neck;   N,  subclavian  aneurysm. 


or  nodulated. 
(g)  Whether  larger  af- 
ter  eating   and   then    smaller  again  as  is  the  case  in 
pressure  diverticula  of  the  esophagus. 
C.  Examination  of  Blood,  Spleen,  Mouth,  and  of  Body  in  General.^ 
In  every  case  of  tumor  of  the  neck  one  should  not  omit  the  general 
examination  of  the  patient.     This  should  include  (a)  the  mouth,  ear, 
nose,  and  throat,  with  the  aid  of  the  special  instruments  required  for 
these  purposes;  (b)  the  blood  for  evidences  of  leukemia,  anemia,  or 
leukocytosis;  (c)  the  condition  of  lymph-nodes  in  other  parts  of  the  body, 


174 


SURGICAL    AFFECTIONS    OF    THE   XECK. 


e,  g.,  the  axillge,  inguinal  regions,  peMs,  and  mesenten-;  (d)  the  spleen, 
whether  enlarged  or  not,  as  a  part  of  the  clinical  picture  of  a  pseudoleu- 
kemia or  of  some  cases  of  lymphatic  leukemia;  (e)  the  presence  or  ab- 
sence of  cachexia,  etc. 

D.  Auscultation  and  Percussion. — These  are  of  Httle  value  in  the 
diagnosis  of  tumors  with  the  exception  of  the  bruit  heard  over  aneur}'sms 
of  the  common  carotid  and  subclavian  arteries. 

Classification. — Tumors  of  the  neck  are  most  conveniently  divided 
into  the  cystic  and  solid  varieties  for  diagnostic  purposes. 


I.  Those     which     are 
congenital  in  origin. 


Cystic. 

1.  Branchial    cysts. 

2.  Th}Troglossal  cysts. 

3.  Lymphangioma    cysti- 

cum. 


4.  Hemangioma  caverno- 
l  sum  and  blood-cysts. 

5.  Th}Tohyoid  bursae. 

6.  Cystic  goiter. 

7.  Diverticula      of     the 
esophagus. 


II.  Non-consenital . 


8.  Cysts  of    accessory  or 

parathyroids. 

9.  Echinococcus  cysts. 

ID.  Sebaceous  cysts. 

11.  Dermoid  cysts. 

12.  Suppurating  lymph- 

nodes  (most  often  of 
a  tuberculous  nature). 


Solid. 

1.  Lipoma — diffuse    or    sym- 

metrical. 

2.  Fibroma. 

3.  Lymph-nodes — tubercu- 

lous, sj-philitic,  or  leu- 
kemic, lymphosarcoma 
(see  page  165). 

4.  Osteoma. 

5.  Chondroma. 

6.  Sarcoma,  including  carotid 

tumors. 

7.  Carcinoma — 

Primar}-:  From  the  skin 
or  branchiogenic  in 
origin. 

Secondar}-:  To  primary^ 
focus  in  head,  lar}-nx, 
thyroid;  esophagus,  or 
breast. 

8.  Tumors  of  the  submaxillary 

salivan.'  gland. 

9.  Goiter,  benign  and  malig- 

nant. 
ID.  Aneurysms  of  common  car- 
otid or  subclavian  arteries. 

1 1 .  Primary  tumors  of  the  paro- 

tid extending  to  the  neck. 

12.  Accessory  thyroids  or  para- 

th%Toids. 


Cystic  Tumors. 

The  chief  characteristics  of  the  various  forms  of  cystic  tumors  of 
the  neck  are: 

I.  Branchial  Cyst. — These  are  generally  located  in  the  submaxil- 
lary region  (Fig.  no)  or  along  the  middle  of  the  inner  border  of  the 
sternocleidomastoid.     It  has  the  sensation  of  a  tense  cyst,  is  oval,  and 


TUMORS    OF   THE    NECK. 


175 


is  firmly  attached  to  the  deeper  tissues.     The  skin  is  movable  over  it 


Fig.  iio. — Front  View  of  Braxchtal  Cyst. 


Fig.  III. — Side  View  of  a  Unilocular  Branxhial  Cyst. 
Observe  its  position  in  the  superior  carotid  triangle  of  the  neck. 


176 


SURGICAL  AFFECTIONS  OF  THE  NECK. 


unless  suppuration  has  occurred.  They  appear  at  birth  but  may  not 
begin  to  enlarge  sufficiently  to  be  recognized  until  adult  life.  The 
contents  may  be  serous,  mucoid,  or  sebaceous.  They  are  most  often 
monocular. 

2.  Thyroglossal  Cysts. — These  are  always  in  the  median  line 
between  the  hyoid  bone  and  the  middle  of  the  trachea.  They  are 
monocular  like  the  branchial  cysts,  are  usually  small,  and  move  upward 
when  the  patient  swallows.  They  cannot  be  distinguished  from  cystic 
lymphangioma,  except  by  microscopic  examination. 

3.  Congenital  Cystic  Lymphangioma. — These  may  occur  either 
as  monocular  or  multilocular  tumors,  most  frequently  situated  in  the 

submaxillary  region. 
Less  often  they  are 
found  beneath  the  occi- 
put and  in  the  supra- 
clavicular region.  They 
arise  from  dilated 
lymph-vessels  and  vary 
from  a  small  tumor  to 
one  occupying  half  of 
the  neck  (Fig.  112). 
They  push  their  way 
like  the  hemangiomata 
between  various  struc- 
tures of  the  neck,  but 
rarely  cause  compres- 
sion symptoms.  They 
are,  however,  subject  to 
recurrent  attacks  of  in- 
flammation, during  which  they  increase  in  size  and  the  skin  over  them 
becomes  reddened. 

They  are  almost  always  present  at  birth.  They  cannot  be  differen- 
tiated from  those  branchial  cysts  of  the  submaxillary  region  which  are 
present  at  birth  except  by  the  fact  that  their  contents  is  a  clear  serous 
fluid  while  that  of  the  branchial  cysts  may  be  pure  serum  or  mucus  or 
sebaceous  material  with  or  without  hair. 

4.  Hemangioma. — This  variety  of  tumor  occurs  in  two  forms  in 
the  neck: 

(a)  Simple  and  Cavernous  Hemangiomata. — These  are  multilocular 
and  may  occupy  one  side  of  the  neck  (Fig.  112),  contain  blood  and  grow 
in  all  directions  but  rarely  cause  pressure  symptoms. 


Fig.  112. — Congenital  Cystic  Lymph  Hemangioma  of  Neck. 


TUMORS   OF   THE   NECK. 


177 


(b)  Unilocular  or  Blood-cysts. — They  vary  from  a  walnut  to  a  child's 
head  in  size,  are  movable,  and  not  attached  to  the  skin.  They  often 
cause  pressure  symptoms  such  as  dyspnea  and  dysphagia.  They  must 
be  differentiated  from  aneurysms,  cavernous  angiomata,  and  lipomata. 
In  the  first-named  there  is  a  bruit,  thrill,  and  expansile  pulsation.  In 
the  cavernous  angiomata  there  is  a  history  of  their  presence  at  birth 
and  they  are  multilocular.  The  lipoma  is  firmer  and  quite  rare  in  the 
regions  in  which  blood-cysts  are  found. 

5.  Thyrohyoid  Bursae. — These  occur  most  frequently  over  the  thy- 
roid cartilage  (bursa  ante- 
thyroidea)  or  on  the  thyro- 
hyoid membrane.  They  are 
the  size  of  a  small  nut  and 
accompany  the  movements 
of  the  thyroid  in  swallowing, 
and  are  apt  to  be  painful  at 
times  in  rheumatic  persons. 
They  must  be  differentiated 
from  cysts  of  an  aberrant 
thyroid. 

6.  Cystic  Goiter.— This 
usually  involves  one  or  both 
of  the  lateral  lobes  of  the  thy- 
roid. It  may  be  of  large  size 
and  cause  considerable  ele- 
vation of  the  skin  (Fig.  113). 
It  gives  a  distinct  sense  of 
fluctuation. 

7.  Diverticula  of  the 
pharynx  or  esophagus  are 
always  on  the  left  side  and 
there  is  a  history  of  their 

alternately  full  and  empty  condition.     They  are  quite  rare  in  the  neck. 

8.  Cysts  of  the  Accessory  Thyroids  and  of  Parathyroids.— 
These  are  found  in  the  typical  location  of  these  structures  (Fig.  108) 
and  are  quite  small  and  appear  usually  after  the  age  of  puberty. 

9.  Echinococcus  cysts  are  quite  rare  and  are  found  close  to  the 
sheath  of  the  carotid  vessels  or  in  the  stemomastoid  itself.  They  cannot 
be  differentiated  from  tuberculous  lymph-node  abscesses  except  from 
the  history  of  a  solid  tumor  which  has  softened  and  is  quite  adherent. 
This  speaks  for  tuberculosis. 


Fig.  113. — Anterior  View  of  an  Enormous  Cystic  Goiter. 
It  occupied  all  the  space  between  the  sternocleido- 
mastoid muscle  on  either  side,  the  lower  jaw  above,  and  the 
sternum  below,  and  contained  a  brownish  gelatinous  fluid 
with  cholesterin  crystals. 


178 


SURGICAL   AFFECTIONS    OF   THE   NECK, 


10.  Sebaceous  Cysts. — These  are  quite  superficial,  small,  and 
stretch  the  overlying  skin  over  it  considerably.  They  may  also  be 
adherent  to  the  skin. 

11.  Dermoid  cysts  occur  in  the  median  line,  especially  just  below 
the  chin.  They  are  firmer  and  more  doughy  in  consistency  than  any  of 
the  other  cysts  occurring  in  these  locations. 


Solid  Tumors. 

1.  Lipoma ta. — These  usually  occur  at  the  back  of  the  neck  as 
subcutaneous  soft  tumors,  not  adherent  to  the  skin.     They  are  usually 

more  or  less  fixed  at  their 
base  and  when  the  skin  is 
stretched  over  them  during 
examination,  showing  a  dis- 
tinct diversion  into  lobules. 
They  may  attain  an  enor- 
mous size. 

A  form  of  diffuse  lipoma 
(Fig.  115)  may  occur  in 
which  the  fatty  tissue  grows 
indiscriminately  between 
the  other  structures  of  the 
neck,  burrowing  between 
the  muscles  and  vessels. 
This  condition  may  be 
present  in  connection  with 
a  peculiar  form  of  multiple 
fatty  tumors  situated  more 
or  less  symmetrically  over 
the  entire  body  and  called 
symmetrical  lipomatosis.  A 
deep  or  subfascial  form  also 

rarely  occurs  which  simulates  the  softer  forms  of  sohd  tumors,  such  as 

goiter  or  tense  cystic  tumors. 

2.  Chrondromata  are  very  rare  and  arise  from  aberrant  islands  of 
cartilage.  The  skin  is  movable  over  them  and  their  firm  consistence, 
hke  that  of  the  cartilage  of  the  nose,  renders  their  diagnosis  easy.  They 
occur  in  young  people. 

3.  Osteomata  usually  occur  in  the  lower  part  of  the  neck  as  out- 
growths from  the  spine,  ribs,  and  clavicles.  Their  bone-Hke  consistency, 
location,  and  fixation    aid    in  differentiating  them  from  every  other 


Fig.  114. — Large  Cystic  Goiter. 
Extending  from  level  of   lower  jaw  almost  to  sternum. 
This    patient  also  had  a  marked  kyphosis,  due  to  old  age. 
(Side  view  of  same  patient  shown  in  Fig.  113.) 


TUMORS    OF   THE    NECK. 


179 


form  of  solid  tumors,  even  without  the  use  of  the  x-ray.  The  only 
condition  which  resembles  an  osteoma  at  the  base  of  the  neck  is  a  cervi- 
cal rib,  which  was  described  on  page  148.  Such  a  supernumerary  rib  is 
thinner  and  more  frequently  causes  pressure  of  the  adjacent  nerves  and 
vessels  than  an  osteoma. 

4.  Fibromata. — These  usually  occur  as  soft  pedunculated  tumors 
of  the  skin,  often  associated  with  a  generalized  condition  of  fibroma 
molluscum  (Fig.  376). 

5.  Solid  Tumors  of  the  Submaxillary  Salivary  Gland  (Fig.  116). — 
These  appear  in  the  typical  location  of 

the  submaxillary  salivary  gland  on  the 
inner  side  of  the  body  of  the  lower  jaw 
close  to  the  angle.  They  are  either 
chondromata  or  mixed  tumors  and 
must  be  differentiated  from  enlarge- 
ment of  the  submaxillary  lymph-nodes 
due  to  tuberculosis  or  malignant  disease 
(such  as  carcinoma).  The  former  may 
be  excluded  by  the  firm  consistency  of 
the  tumor  and  the  latter  by  the  absence 
of  a  primary  growth. 

6.  Goiter. — Here  the  tumor  is  situ- 
ated in  the  region  usually  occupied  by 
the  thyroid  gland  along  either  side  and 
across  the  middle  of  the  trachea  (Fig. 
119).  It  may  be  soft  or  quite  firm, 
varying  in  this  respect  according  to 
whether  it  is  parenchymatous,  colloid, 
or  fibrous  in  character.  When  the 
patient  swallows  a  glass  of  water  the 
tumor  moves  upward  on  account  of 
its  attachment  to  the  trachea.  The 
skin  is  movable  over  the  tumor.  Goiter  is  considered  in  detail  on  page 
185. 

7.  Sarcomata. — These  arise  in  the  deeper  parts  of  the  neck  and 
grow  toward  the  surface.  They  may  arise  from  the  following  struc- 
tures : 

(a)  The  carotid  body. 

(b)  The  connective  tissue  of  the  carotid  sheath. 

(c)  As  lymphosarcomata  from  the  cervical  lymph-nodes. 

(d)  From  the  thyroid  gland. 


Fig.  115. — Symmetrical  Lipomatosis. 
In  this  case  the  entire  neck  from  the 
sternocleidomastoid  on  each  side  was  oc- 
cupied by  a  diffuse  hpomatous  tumor.  Li- 
pomata  were  distributed  symmetrically  over 
both  deltoid  regions,  over  the  abdomen  on 
either  side  of  the  median  line,  and  over  both 
gluteal  regions. 


I50  SURGICAL    AFFECTIONS    OF   THE   NECK. 

(a)  Sarcomata  Arising  from  the  Carotid  Body  (also  called  Luschka's 
gland). — They  are  usually  endotheliomata  and  appear  in  middle-aged 
or  old  people.  The  tumor  is  of  ver^^  rapid  growth  and  is  situated  at 
the  point  of  bifurcation  of  the  common  carotid  artery.  It  invades  the 
vessel  sheath  in  its  growth.  The  tumor  is  soft  and  compressible,  attain- 
ing the  size  of  a  hen's  egg,  and  shows  no  expansile  pulsation  or  thrill  like 


Fig.  ii6. — Solid  Tumor  of  tiee  Submaxillary  Salivary  Gland. 

This  illustration  shows  how  these  tumors  appear  to  come  from  behind  the  lower  jaw,  projecting  outward  in 

the  submaxillary  -region.     (See  text.) 


an  aneurysm.  It  is  much  firmer  than  a  branchial  cyst,  appears  at  a 
later  period  in  life,  and  grows  more  rapidly.  It  has  a  transmitted 
pulsation  due  to  its  relation  to  the  vessels. 

(b)  Sarcomata  arising  jrom  the  carotid  sheath  itself  grow  rapidly  and 
are  firmly  fixed  to  the  deeper  structures  of  the  neck,  although  they  are 
not  adherent  to  the  skin  until  a  later  period  when  they  may  ulcerate  and 


TUMORS    OF   THE   NECK. 


I«I 


present  a  sloughing  mass.  They  cause  pressure  symptoms  such  as 
dysphagia,  dyspnea,  neuralgia,  and  recurrent  laryngeal  paralysis  at  an 
early  stage  of  their  growth. 

They  are  of  firm  consistency  and  usually  occur  in  middle  or  old 
age.  Their  location  under  the  sternocleidomastoid  muscle,  rapid 
growth,  fixation  to  the  deep  structures,  and  pressure  symptoms  render 
their  diagnosis  comparatively  easy.  Lymphosarcomata  and  sarcoma 
of  the  thyroid  are  discussed  on 
page  187. 

9.  Carcinoma. — This  form 
of  tumor  of  the  neck  may  be 
primary  or  secondary.  The 
former  are  very  rare  and  may 
arise  in  the  skin  either  (a)  from 
an  old  ulcer  or  a  scar  or  (b)  in 
the  deeper  tissue  from  the 
branchial  cysts  or  fistulae  or 
from  aberrant  thyroids. 

(a)  Primary  Carcinoma. — 
The  cutaneous  carcinomata  pre- 
sent the  same  characteristics  as 
elsewhere.  The  deeper  forms 
of  primary  carcinoma  are  usu- 
ally rapid  in  their  growth  and 
located  just  below  the  angle  of 
the  jaw  or  at  the  middle  of  the 
sternocleidomastoid  muscle  at 
the  same  location  as  the  branch- 
ial cyst  (Fig.  100).  They  occur 
late  in  life  and  become  adherent 
to  the  vessels  early  and  cause  ul- 
ceration of  the  skin,  with  evert- 
ed hard  edges  (Fig.  loi).  The  diagnosis  of  a  primary  branchiogcnic 
carcinoma  may  be  made  if  the  growth  has  the  typical  induration  of 
carcinoma,  situated  in  the  usual  cyst  location  of  a  branchial  cyst.  They 
are  fixed  and  cause  pressure  symptoms  only  at  a  late  period.  The  growth 
is  harder  than  a  sarcoma  and  there  is  often  involvement  of  the  regional 
lymph-nodes  (deep  cervical). 

Primary  carcinoma  of  the  thyroid  is  lower  in  the  neck  and  attached 
to  the  trachea  and  displaces  the  latter  (Fig.  117). 

(&)  Secondary  Carcinoma. — This  form  of  solid  tumor  can  be  readily 


Fig.    117. — Anterior   View   of  Carcinoma   of  the 
Thyroid. 
Causing  displacement  of  the  trachea  {T)  to  the 
left:   G,  Secondary  enlargement  of  the  cervical  lymph- 
nodes,  of  a  carcinomatous  nature. 


SURGICAL  AFFECTIONS  OF  THE  NECK. 


diagnosed  from  the  fact  that  it  involves  the  lymph-nodes  draining  the 
mouth,  nose,  ear,  pharynx,  or  thyroid  (Fig.  74).  They  are  very  hard, 
cause  early  pressure  symptoms,  and  hke  the  sarcomata  and  primary 
carcinomata  ulcerate  quite  early.  The  diagnosis  can  be  made  from  the 
consistency  of  the  tumor  and  its  location.  The  latter  corresponds 
with  that  of  the  lymph-nodes.  One  should  search  for  a  primary  growth 
in  the  head,  larynx,  esophagus  and  thyroid,  breast  or  stomach  (supra- 
clavicular nodes).     The  latter  is  a  rare  occurrence. 

At  times  the  external 
tumors  may  be  enormous 
and  even  bilateral  and 
the  primary  growth  be 
an  insignificant  one,  hid- 
den in  some  obscure  place 
like  the  sinus  pyriformis 
or  the  anterior  wall  of 
the  pharynx.  One  should 
always  examine  in  their 
order  the  face,  mouth, 
tongue,  nasopharynx,  lar- 
ynx, esophagus,  ear,  sal- 
ivary glands,  thyroid,  and 
rarely  the  stomach. 

Primary  carcinoma  of 
the  esophagus  may  at 
times  first  involve  the 
submaxillary  nodes  to 
such  an  extent  that  the 
tumor  is  diagnosed  as  a 
primary  one  of  the  sub- 
maxillary salivary  gland. 
The  secondary  car- 
ciQomatous  nodes  are  often  movable  and  painless  for  a  considerable 
period  and  may  be  the  first  sign  to  direct  suspicion  toward  a  malignant 
growth  in  the  region  which  they  drain.  They  are  much  firmer  than 
tuberculous  nodes  and  the  latter  are  very  rare  at  such  a  late  period  of 
hfe.  Primary  branchiogenic  carcinomata,  as  was  stated  above,  become 
adherent  quite  early  to  the  vessels  and  cause  severe  pain. 


Fig.  118. — Lateral  View   of   Case  of    Carcinoma  of   the 
Thyroid. 


TUMORS    OF   THE    NECK. 


183 


>    ,n 


«^    77^ 


>  -h 


%--^ 


0 

bb 

T32 
C 

^ 

0 

3 

3 
u 

5 

rt 

0 

0 
0 

0 
rl 

u 

3 

0 

n 

D 

"S 

>.^ 

a 

u 

p 

0 

s 

3 

^  ill, 

.S  ^ 

ii  be 

0 

3 

0 

.tl  0 

J^ 

E 

_0 

'S 

u 

"0 
C/3 

>+H      P^,     17 


^^.^ 


Td  -^  .3 

tfi    C3    _1    " 

O     O     ^  i-M 


*^      > 


^  ^ 


(^3 


U  .3 

^-^ 
•,-•  en 
Pm 


£  ■"  c« 

rf    O    >> 


^,U 


«  d  0 


O  " 


12 


"^  o 

.2  "^ 

bJD'S 

(Ti    *+-< 

i  ° 

3-13 

in 


ae^ 


3 

■2'o 


T3  :n    .4:J 


3   o 


< 


.2  "B 
'5b  o 


0.2  3 
>  t-  o 

c3-^ 


1-1  *^ 


^    S 


6< 


VI  u 


cAi    rt  I  -^  O 


o  "  < 


^  £     o 


^    3 


3    b£ 
3 


bO 


H 


u 


i84 


SURGICAL    AFFECTIONS    OF   THE    NECK. 


X 

u 

>-. 

i  J: 

o 

3 

c 

o 

■55  p; 

accord 
hymato 
maligna 

o 

cfi 

•^ 

B 

u 

>. 

£  3  b 

^    C    t-i 

1) 

o     • 

c 

3 
en 

u 

>^ 

u 

C 
o 

Grows     rapidly, 
varies  from  soft 

hard  and 
d    infectio 
s  in  prima 

."2 

e 
0 

stenry    var 
hcther  pai 
id,  fibrous. 

i;  o 

E 

>. 

o 
> 

c 

0 

U 

Very 
gion 
node 

Consi 
to  w 
collo 

■  r^       !/}       r-  3        U 

o    c        c  > 


1)     O     C 


"-    o    g 


i     s 

W 
(il 

None  unless 
fuse  variety 

i 

0 
C 
0 

None       exce 
Hoflgkin's  c 
or  lymphosa 

None    exce])t 
ralgic  pains, 
slow  growth 

i     0 

Quite    early 
sure    on    tr 
e  s  0  p  h  a  g  u 

vessels. 

Same  as  abo-v 
primary    a 
growth.  Lat 
sure  sympto 
secondary. 

m 
T; 

3 

0    d 

^   d 
in   -^ 
^    C 
in    0 

13 

S 
0 

-3 

0    S 

c 

3 

> 
0 

0 

0 

)     in 
in 

cS      • 
>^ 
^^ 

0    rf 

3 

XI 

•s  a 

.S  S  i 
3h  .^ 

.g  1n   g 
X    d    S    S 

0 

ii 

u  3 

.    d    kS 

(u  2  ^ 

2    -^     03 
d    0    4j^ 

0 
< 

3 
< 

3 
< 

6 

c 
< 

3 
< 

d 

in 

C 

< 

< 

bO 

d 

0 

3 

< 

a, 
0 

3 

bO    . 

!5 

0 

H 

H 

H 
0 

0         tn        ^3  '-/J         0 
§        3         go          ^ 

0              C            r^    rt              bC 

-^          2    .      c  o-o      ^ 
0               ^     c  c  ^      > 

-s  .    a  =1  i  £;  3    ^ 

"o 

in 

C 
In 

s 

d  0  to:          i^  .5  •-' 

^S"         g  "  b 

in'^  g           33 

0      0      0                            0      L,      C 

"B^^     !  ^  °  S 

■i     -  0        !     y  In 
^  a.  o-  >      ^  -^  €  ^' 

3 

0 
3d 

c 

d 

_o 

"0 
« 

> 
0 

0 

X. 

^  i 

t  6 

d 
in   0 

U    D 
1^ 

g 

0 

0 

5 

3 
6 

c 

0 
a 

en 

<u 

-a 
c 
c 

-S   ■ 
>.  c 

r^               1 

'in                I 

0 
4 

s 

0 

c 

u     1 

5 

E 
0 
0 

d                     1 

. 
0 

d 
d 

E 
c 
_c 
'5 
d 

u 

_d 
d 

E    . 

«J   d 
■^"bb 

if)  ^ 

11 

OC" 

aj     , 
3 

TUMORS    OF   THE   NECK, 


l8  = 


XJ 

V                   I 

c 

bO 

a 

03 

3 
u 
^ 

1-. 
u 

■*-• 

aj 

.2 

.^ 

j2 

*■*-» 

Pl     . 

3 

rt 

(1;  /^ 

-r) 

t/3 

3 

o 

Oh 

•rt   S 

I-    n! 

c  S 

M=l    lO, 

o 

f^3 

a" 

^^ 

> 

(U 

^^x) 

-0  A 

1 

1/1 

"c 

'c 

O    c/1 

0 

^      ^ 

!-( 

S& 

J  g  3 

O    rt 

O   rt   b„ 

^- 

^-  ^ 

T3 

.2 

<     • 

^ 

Dh 

Qj 

0) 

> 

o 

rt  +j 

>-. 

c3 

>    c3 

O  -73 

O  ^ 

eg 

-5    C 

O 

Id    tn 

.S  fe 

a 

M  ,fl 

-.'-'    tn 

ai 

CO 

ti< 

C/3 

_>^ 

n! 

3 

tn 

3 

3 

,0 

aT 

bC^J 

3 

3 

X) 

-o 

< 

< 

.  lA 

M 

a 

E 

CJ 

'S 

CU 

aj 

^ 

aj 
en 

3 

S^ 

i/i 

d 

dJ 

u 

^ 

o 

^ 

12 

O 

'S 

1 

3 
O 

nj 

c   ii 

'|~! 

o 

•-    C 

c« 

bD 

e;  o 

C 

■^Tr,'^ 

O 

?f  t« 

^  o 

< 

<  "" 

1 

t-f 

oj 

o 

fl, 

•s 

i" 

s^ 

o 

y^f 

■^ 

cS  X) 

<A 

B 

3 

o  ^ 

tn 

>, 

„    rC 

t' 

feT5 

3 

1-.  i- 

.C 

o  a, 

< 

Ph 

O 

6 

M 

1   <^              i 

•-* 

M 

k-< 

Non-malignant  Goiter. 

This  may  involve  the  thyroid  gland  proper, 
or  one  of  the  accessory  thyroids  or  parathyroids. 
The  pathologic  changes  are  the  same  in  all  and 
the  diagnosis  of  which  one  is  involved  can  only 
be  made  from  the  location  (Fig.  io8). 

The  chief  questions  in  every  case  of  non-mahg- 
nant  goiter  are: 

(a)  Whether  the  suspected  tumor  is  a  goiter. 

(b)  What  is  the  extent  of  the  involvement  and 
the  variety? 

(c)  Are  pressure  symptoms  present? 

A  goiter  of  the  accessory  or  parathyroids  will 
have  all  the  clinical  characteristics  of  the  true 
goiter,  but  its  situation  is  different  and  it  is  not 
attached  to  the  trachea. 

A  goiter,  involving  the  thyroid  gland  proper 
causes  a  prominence  in  the  lower  portion  of  the 
neck  (Fig.  119)  best  seen  when  looked  at  from  the 
side.  It  may  be  most  marked  in  the  median  line 
if  it  involves  the  isthmus  or  more  on  one  side  if 
one  lobe  is  involved,  or  be  butterfly-hke  causing 
a  prominence  on  both  sides  connected  by  a  bridge 
(Fig.  119). 

Tumors  of  the  thyroid,  unless  a  brawny,  board- 
hke  infiltration  exists,  move  upward  with  the  tra- 
chea. This  can  be  determined  by  permitting  the 
patient  to  swallow  some  water  while  the  tumor  is 
grasped  with  the  fingers  (Fig.  121).  This  is  ab- 
sent in  goiters  of  the  para-  or  accessory  thyroids. 

The  extent  of  involvement  can  be  ascertained 
by  flexing  the  head  upon  the  neck  and  palpating 
the  tumor  while  standing  behind  the  patient. 

The  varieties  of  enlargement  are: 

I.  Simple  Parenchymatous. — This  occurs  at 
any  age  but  is  especially  frequent  in  young  people. 
It  usually  involves  the  entire  gland,  is  soft  and 
smooth,  and  rarely  causes  pressure  symptoms.  It 
may  give  the  sensation  of  fluctuation.  Any  of 
the  other  forms  may  develop  in  it.  It  may  begin 
during  adolescence  or  pregnancy  and  remain 
stationary. 


SURGICAL    AFFECTIONS    OF   THE   NECK. 


2.  Thyroid  Adenoma. — This  is  the  most  frequent  form.     It  causes 

firm  nodular  tumors  whose  outhnes  are  quite  sharp.     It  often  contains 

small  cysts  and  its  acini, 
which  resemble  those  of 
the  normal  thyroids,  may 
coalesce  to  form  large 
fluctuating  cysts  form- 
ing very  prominent  tu- 
mors (Fig.  113).  This 
form  (adenoma)  involves 
only  a  portion  of  the 
gland,  either  one  lobe 
(Fig.  122)  or  the  isthmus. 
Pressure  symptoms  such 
as  dyspnea  are  marked 
if  it  compresses  the  tra- 
chea. If  smaller  or 
larger  collections  of  col- 
loid material  occur  it 
gives  it  a  doughy  con- 
sistency. 

3.  Fibrous  Goiters. — 

These  occur  as  enormously  hard  nodules  or  as  a  diffuse  induration  of 

one  lobe  or  of  the  entire  gland.     In 

the  latter  form  they  cause  pressure 

symptoms  quite  early. 

4.  Vascular  Goiters. — This  variety 

presents  a  distinct  pulsation  or  thrill 

of  the  goiter  due  to  the  enlargement 

of  the  vessels.     There  are  murmurs 

to  be  heard  over  the  tumor. 

Pressure     symptoms     are     most 

marked  if  the  posterior  part  of  one 

or  both  lateral  lobes  are  involved,  or 

if  there  is  a  retrosternal  goiter.    These 

pressure  symptoms  are: 

(a)  Those  due  to  pressure  on  the 

trachea.     If  moderate  there  is  dysp- 
nea, cyanosis,  and  some  stridor.     If 

the  pressure  is  of  high  degree  asphyxia 

may  result  (Fig.  117). 


Fig.  119. — Parenchymatous  Goiter. 
Causing   enlargement  of  right  (i?)  and  left  (i)  lateral  lobes 
and  isthmus  {M)  of  thyroid.    The  palpable  outlines  of  the  tumor  are 
traced  upon  the  neck  in  black. 


Fig.  120. — Lateral  View  of  Same  Case 
Shown  in  Fig.  iig,  of  Parenchymatous 
Goiter  Involving  Isthmus  and  Lat- 
eral Lobes. 


TUMORS    OF   THE    NECK. 


187 


y. 


The  extent  of  this  pressure  on  the  trachea  may  be  ascertained  by  a 
laryngoscopic  examination  and  tlie  use  of  the  x-ray  as  recently  sug- 
gested by  von  Bruns. 

(b)  Pressure  on  the  recurrent  laryngeal  nerve.  This  causes  hoarse- 
ness, a  brassy  cough,  and  aphonia.  Death  may  ensue  suddenly  from 
spasm  of  the  glottis. 

(c)  Pressure  on  the  sympathetic  causes  vasomotor  disturbances  of 
the  skin  of  the  face  and 

neck  and  a  dilatation  of 
the  pupil  on  the  side 
upon  which  pressure  is 
exerted. 

(d)  Pressure  on  the 
esophagus  is  less  frequent 
than  any  of  the  above  and 
results  in  diiSculty  in 
swallowing. 

A  retrosternal  goiter 
produces  dullness  over 
the  manubrium  (Fig. 
148),  may  cause  pressure 
on  the  trachea,  and  this 
tracheal  stenosis  be  the 
only  symptom.  It  may 
also  compress  the  large 
veins,  the  innominate  ar- 
tery, and  the  esophagus. 

A  retrosternal  goiter 
must  be  differentiated 
from  other  conditions, 
such  as  other  varieties  of 
mediastinal  tumor,  such 
as  sarcomata,  aneurysms, 
and  esophageal  divertic- 
ula which  could  produce  the  same  symptoms  (see  page  329).  In  retro- 
sternal goiter  the  dyspnea  is  intermittent,  varying  with  the  rise  and  fall 
of  the  tumor  during  respiration. 


./ 


Fig.  121. — Method  of  Grasping  Tumors  of  the  Thyroid  to 
SHOW  their  Relation  to  the  Trachea. 
The  lobes  of  the  enlarged  thyroid  are  grasped  between  the 
index-finger  and  thumb,  and  the  patient  instructed  to  swallow. 
During  the  act  of  swallowing  the  tumor  moves  distinctly  upward, 
and  sinks  again  after  cessation  of  the  same. 


Malignant  Goiter. 
Both  sarcoma  and  carcinoma  occur  rather  infrequently.     Sarcoma 
occurs   at   an   earher  age    (thirty  to   fifty)   than  carcinoma   (forty   to 


SURGICAL  AFFECTIOXS  OF  THE  NECK. 


sixty).  Sarcoma  grows  more  rapidly  than  carcinoma  and  attains  a 
much  larger  size.  Both  can  be  distinguished  from  non-malignant 
goiters  by  the  fact  that  they  cause  a  steady,  at  times  quite  rapid,  enlarge- 
ment of  the  gland  and  the  pressure  symptoms  on  trachea,  esophagus, 
and  blood-vessels  are  ver}'  marked  (Fig.  117).  Both  forms  of  tumor  are 
much  harder  than  the  ordinary  forms  of  goiter.  Sarcoma  causes  a 
uniformly  rapid  enlargement  while  carcinoma  is  quite  nodulated,  accom- 
panied by  enlarged  hard  lymph-nodes,  and  is  very  painful. 

Carcinoma  of  the  thy- 
roid produces  early  metas- 
tases in  the  long  bones  and 
skull. 

Thyroiditis. 
Inflammations  both  of 
the  normal  thyroid  gland 
and  of  a  goiter  may  occur. 
The  symptoms  are  identi- 
cal in  both. 

They  may  follow  injury 
to  the  neck  in  the  vicinity 
of  the  gland  or  occur  dur- 
ing the  course  of  some 
general  disease,  such  as 
typhoid,  malaria,  articular 
rheumatism,  scarlatina, 
variola,  and  pyemia.  The 
diagnosis  presents  no  dif- 
ficulties if  one  remembers 
the  normal  situation  of  the 
The  gland  can  be  felt  to  be  considerably  swollen  and  in- 
It  is  quite  tender  and  the  pains  radiate  toward  the  face  and 
In  the  very  acute  cases  there  is  redness  of  the  overlying  skin. 
The  leukocytosis,  pulse-rate,  and  temperature  vary  with  the  severity 
of  the  infection,  being  higher  in  the  very  acute  cases.  The  swollen 
gland  may  compress  the  trachea  and  esophagus  and  cause  symptoms  of 
stenosis,  dyspnea,  and  dysphagia  respectively.  If  the  inflammation 
goes  on  to  suppuration  the  surrounding  tissue  becomes  edematous  and 
tender  and  pus  forms  in  the  gland.  This  may  be  ascertained  by  the 
persistence  of  the  temperature  and  the  increase  of  the  local  signs  and 
leukocytosis. 


y 


Fig.  122. — Unilateral  Right-sided  Goiter. 
The  arrow  points  to  the  tumor  along   the   inner  side  of 
the  lower  portion  of  the  sternocleidomastoid  muscle,  caused  by 
the  goiter. 


thyroid. 
durated 
the  ear. 


TUMORS    OF   THE    NECK. 


189 


The  pus  may  escape  externally  through  perforation  of  the  skin  or 
rupture  into  the  trachea,  esophagus,  or  mediastinum. 

Exophthalmic  Goiter. 

The  diagnosis  of  this  condition  may  be  made  from  the  presence  of 
a  group  of  four  symptoms,  exophthalmos,  tachycardia,  a  goiter,  and  a 
fine  tremor. 

It  may  occur  as  a  disease  without  any  marked  enlargement  of  the 
thyroid  or  be  accompanied  by  any  of  the  forms  of  goiter. 


Fig.  123. — Front  View  of  Case  of  Exophthalmic 
Goiter. 
The  bulging  of  the  eye  resulting  in  abnormal 
separation  of  the  lids  is  well  shown.  The  thyroid 
was  greatly  enlarged,  of  the  parenchymatous  variety, 
and  involved  both  right  and  left  lobes  and  the 
isthmus  oi  the  thyroid,  all  of  which  were  quite 
prominent.     The  pulse-rate  in  this  case  was  152. 


Fig.    124. — Side    View   of  Case  of   Exoph- 
thalmic Goiter. 
Note  the  protrusion  of  the  eyeballs  and  the 
marked  prominence  over  the  thyroid  region,  due 
to  the    presence   of   a  parenchymatous   goiter  of 
both  lobes  and  isthmus  of  the  thyroid. 


The  exophthalmos  is  bilateral  and  (Figs.  123  and  124)  accompanied 
by  certain  typical  ocular  symptoms  which,  however,  are  not  constant. 
These  latter  are  the  Stellwag  symptom  (abnormal  wideness  of  the 
palpebral  opening),  the  Moebius  symptom  (a  lack  of  convergence  of 
the  two  eyes),  and  the  von  Graefe  symptom  (the  upper  lid  does  not 
follow  the  eyeball  when  it  is  moved  down).  The  tachycardia  varies 
from  ninety  to  one  hundred  and  forty  beats  or  even  higher  in  severe 
cases.  The  face  and  neck  are  Hushed  and  there  are  frequent  attacks 
of  profuse  sweating,  especially  of  the  extremities. 


190 


SURGICAL  AFFECTIONS  OF  THE  NECK. 


The  goiter  is  moderately  firm,  not  as  large  as  in  ordinary  cases,  and 
often  so  vascular  as  to  show  a  distinct  bruit. 

The  tremor  is  of  a  very  fine  character,  best  seen  when  the  hands 
are  extended.     There  is  often  great  muscular  weakness  (myasthenia). 

From  time  to  time  there  are  attacks  of  vomiting  and  diarrhea  as 
well  as  of  palpitation  and  angina  pectoris. 

The  lan^al  or  formes  frustes  often  accompany  goiters,  but  are  apt  to 
be  overlooked.  In  these,  any  of  the  above  symptoms,  such  as  tachy- 
cardia, tremor,  sweating,  and  palpitation,  may  accompany  a  goiter  and 
not  be  correctly  interpreted. 


Edema  of  the  Glottis. 
This   is   usually   secondar}'    to   inflammmatory   conditions   in   the 
vicinity  spreading  to  the  loose  connective  tissue  of  the  aryepiglottic 

folds.  The  swelling  causes  marked 
dyspnea,  cyanosis,  and  stridor.  The 
s}Tnptoms  may  appear  so  rapidly 
that  death  occurs  immediately.  The 
diagnosis  may  be  made  from  the 
onset  of  the  above  symptoms  during 
the  course  of  a  peritonsillar  (Fig.  1 25) 
or  perichondritic  suppuration  or  as 
a  comph cation  of  a  Lud wig's  angina 
(deep  phlegmon  of  floor  of  mouth) 
or  of  ulcerative  laryngeal  processes. 
The  diagnosis  can  be  confirmed 
by  lar}Tigoscopic  examination.  One 
can  see  the  swollen  aryepiglottic 
folds  almost  touching  each  other. 


#■ 


Fig. 


-Peritonsillar  Abscess. 


PA ,  Prominence  along  anterior  pillar  of  fauces 
and  caused  by  peritonsillar  abscess;  SP,  edema- 
tous uvula;  L,  normal  left  tonsil  and  pillars  of 
fauces;   T,  tongue. 


Papilloma  of  Larynx. 
This  is  the  most  frequent  form 
of  benign  tumor  of  the  larynx.  They 
occur  especially  in  children  on  the  true  vocal  cords  and  are  usually 
multiple.  They  give  rise  to  S3'mptoms  of  stenosis  and  hoarseness  and 
if  pedunculated  may  fall  mto  the  space  between  the  cords  and  cause 
asphyxia.  By  laryngoscopic  examination  they  look  like  a  pink  mul- 
berr}^-shaped  tumor  situated  at  the  anterior  end  of  one  of  the  vocal 
cords  or  scattered  diffusely  over  both  the  cords. 


TUMORS    OF   THE   NECK.  I9I 

Carcinoma  of  the  Larynx. 

Carcinoma  of  the  lar}Tix  usually  occurs  late  in  life.  It  may  be 
primary,  i.  e.,  have  its  origin  within  the  larynx,  or  secondary,  by  extend- 
ing to  it  from  the  tongue,  pharynx,  or  esophagus.  The  primary  is  also 
spoken  of  as  intrinsic,  the  secondary  as  the  extrinsic  form. 

The  diagnosis  may  be  made  from  the  gradual  onset  of  hoarseness, 
pain  in  the  lar}Tix  radiating  to  the  ears,  and  dyspnea  in  elderly  men 
taken  in  conjunction  with  the  local  findings.  Later  on  when  the  lymph- 
nodes  along  the  anterior  border  of  the  stemomastoid  become  enlarged 
and  there  is  expectoration  of  a  fetid,  tenacious  mucus,  with  recurrent 
hemorrhages  accompanied  by  dysphagia  and  emaciation,  the  diagnosis 
is  no  longer  difficult. 

The  local  examination  at  an  early  stage,  will  show  one  of  the  follow- 
ing lar}Tigoscopic  pictures: 

1.  A  papillomatous  growth  which  has  a  broad  indurated  base 
situated  usually  on  the  posterior  third  of  a  vocal  cord. 

2.  As  a  marked  thickening  and  induration  of  one  of  the  vocal  or 
ventricular  bands  or  aryepiglottic  folds.  At  times  one  sees  in  addition 
to  the  induration  a  nodulated  condition.  The  entire  thickness  of  the 
cord  seems  to  be  involved.  Later  in  the  disease,  the  picture  is  different; 
one  now  sees  ulcerations  with  raised  and  indurated  edges.  The  car- 
cinoma has  now  begun  to  grow  either  through  or  around  the  thyroid 
cartilage  and  is  to  be  felt  externally  as  a  hard  mass  accompanied  by 
firm  enlarged  lymph-nodes.  In  the  very  advanced  stages  it  may  grow 
toward  the  trachea,  phar}mx,  or  esophagus,  and  cause  corresponding 
symptoms. 

There  are  a  number  of  conditions  from  which  carcinoma  of  the 
larynx  must  be  differentiated.  These  are  benign  papilloma,  syphilis, 
and  tuberculosis.  The  first-named  occurs  very  rarely  so  late  in  life 
and  according  to  Bland  Sutton  any  papilloma  beyond  the  age  of  forty 
must  be  looked  upon  with  suspicion. 

In  regard  to  the  two  last-named  conditions,  tuberculosis  and  syphihs 
are  always  seen  as  ulcers  and  seldom  as  infiltrations  and  never  papil- 
lomata.  In  tuberculosis  severe'  pain,  cough,  and  dysphagia  are  promi- 
nent symptoms.  The  arytenoids  are  greatly  swollen  and  club-shaped. 
The  tuberculous  ulceration  is  very  shallow,  has  no  indurated  edges, 
and  the  larynx  is  very  anemic.  Tuberculosis  is  never  primary  and  is 
accompanied  by  signs  of  pulmonary  disease  with  tubercle  bacilli  in 
the  sputum.  Tuberculous  ulcers  are  multiple  while  carcinoma  occurs 
in  a  single  place.     Tuberculosis  has  as  a  favorite  seat  the  interarytenoid 


192  SURGICAL    AFFECTIONS    OF   THE   NECK. 

space  or  the  antenoid  cartilages.  Syphilis  is  accompanied  by  signs 
of  the  same  disease  elsewhere  and  if  iodids  are  given  there  is  marked 
improvement  of  the  lar}Tigeal  condition  which  causes  hoarseness  and 
dyspnea  as  does  carcinoma.  The  syphihtic  ulcerations  as  elsewhere 
are  deep  and  the  edges  are  clear  cut  as  though  cut  out  with  a  die,  and 
may  occur  anywhere  in  the  larynx,  but  Hke  tuberculosis  are  usually 
multiple.     There  is  no  enlargement  of  the  lymph-nodes  of  the  neck. 

It  must  not  be  forgotten  that  as  on  the  tongue  carcinoma  may  be 
combined  with  syphihs.     It  is  almost  impossible  to  diagnose  such  cases. 


CHAPTER  III. 

THORAX. 

Injuries  of  the  Bony  Walls  of  the  Thorax. 

The  diagnosis  of  whether  an  injury  has  occurred  and  its  extent  can 
only  be  made  from  a  systematic  examination  of  each  rib,  of  its  costal 
cartilages,  and  of  the  sternum. 


FRACTURES  OF  THE  RIBS. 

If  the  mode  of  injury  has  been  a  blow  received  from  some  blunt  object 
or  a  fall  upon  the  same,  the  fracture  will  usually  be  found  at  the  point 
of  impact.  If  the  thorax  has  been  crushed  in  a  diffuse  manner,  as  in 
being  run  over  or  caught  between  bumpers,  the  fracture  will  usually 
be  found  between  the  midaxillary  line  and  angle  of  the  ribs.  Those 
most  often  broken  are  from  the  third  to  ninth  ribs  inclusive.  Only 
one  rib  may  be  broken  or  a  number  (six  or  seven).  A  single  rib  may 
at  times  be  broken  in  places.  The  diagnosis  of  whether  there  are 
complications,  such  as  injury  of  the  vessels,  pleura,  or  lung,  will  be 
considered  on  page  196. 

The  diagnosis  of  a  fracture  of  a  rib  depends  upon  the  presence  of 
two  classes  of  symptoms. 

1.  Those  due  to  the  fracture  proper,  such  as  pain,  crepitus,  false 
point  of  motion,  and  deformity. 

2.  Those  clue  to  injury  of  the  intrathoracic  viscera. 

I.  Signs  Due  to  the  Fracture  Proper. — These  are  not  as  easily 
ehcited  in  the  ribs  as  in  the  long  bones,  nor  is  it  necessary  to  obtain  all 
of  them  in  order  to  make  a  diagnosis. 

Crepitus  can  rarely  be  elicited  and  no  great  stress  should  be  placed 
upon  its  absence.  It  can  be  obtained  at  times  by  placing  the  hand  over 
the  suspected  point  of  fracture  and  asldng  the  patient  to  breathe  deeply. 
If  this  does  not  eHcit  it,  no  further  effort  should  be  made  to  obtain  it. 
Occasionally  it  may  be  heard  with  the  aid  of  a  stethoscope.  A  false 
point  of  motion  may  often  be  obtained  by  direct  palpation  over  the  seat 
of  fracture  without  causing  pain  to  the  patient.  Each  rib  should  be 
examined  by  palpating  it  from  its  anterior  to  posterior  ends  for  this 
13  193 


194  '     THORAX. 

sign.  One  must  not  mistake  the  apparent  yielding  of  the  lower  ribs 
for  this  sign.  During  the  same  manipulation  one  can  usually  feel  a 
depression  or  unevenness  in  the  outline  of  the  ribs  if  present.  The 
latter  is  especially  true  in  fractures  at  the  costochondral  junction. 

On  placing  one  hand  in  front  and  the  other  at  the  back  of  the  chest 
and  compressing  the  chest,  the  patient  will  experience  a  sharp  pain  at 
the  seat  of  fracture.  The  diagnosis  must  at  times  be  made  from  the 
presence  of  pain  and  deformity  alone,  with  or  without  accompanying 
symptoms  of  intrathoracic  complications. 

2.  Signs  Due  to  Injury  of  the  Intrathoracic  Viscera  (i.  e.,  of 
the  Pleura  or  Lung. — These  are  discussed  on  page  196.  They  are 
friction  rub,  hemothorax,  pneumothorax,  emphysema  of  the  subcu- 
taneous tissuse,  hemoptysis  and  pneumonia. 


FRACTURES  OF  THE  COSTAL  CARTILAGES. 

Fractures  of  the  costal  cartilages  themselves  are  most  common  in 
old  age  when  they  are  ossified,  while  in  younger  persons  there  is  a  sepa- 
ration of  the  cartilage  from  the  ribs.  The  diagnosis  may  be  made 
from  palpation  of  the  deformity,  the  cartilage  itself  being  displaced 
backward,  while  the  rib  is  pushed  out  or  forward.  There  is  also  local 
pain  and  some  degree  of  abnormal  motion. 


FRACTURES  OF  THE  STERNUM. 

Aside  from  gunshot  wounds,  these  are  usually  transverse  and  occur 
in  connection  with  injuries  of  the  spine  as  the  result  of  crushing  in- 
juries of  the  thorax.  They  are  most  common  at  the  junction  of  the 
manubrium  and  gladiolus,  and  next  most  frequent  opposite  the  third 
and  fourth  ribs.  The  diagnosis  may  be  made  from  the  severe 
pain  referred  to  the  site  of  the  injury  and  the  deformity.  The  defor- 
mity may  be  present  either  as  a  decided  displacement  backward  of 
the  manubrium,  so  that  when  the  finger  is  passed  along  the  sternum 
from  above  downward  there  is  a  sudden,  sharp,  step-hke  elevation  at 
the  manubrio-gladiolar  junction.  In  other  cases  there  is  a  marked 
increase  of  the  normal  ridge  or  angle  (angulus  Ludovici)  which  these 
two  portions  of  the  sternum  form  with  each  other. 

Fractures  of  the  sternum  may  be  accompanied  by  signs  of  severe 
intrathoracic  injury. 


Fig.  126. — Illustration  of  a  Case  of  Traumatic  Asphyxia  (see  text)  Following  Com- 
pression OF  the  Thorax.  (Kindly  lent  by  Drs.  H.  H.  A.  Beach  and  Farrar  Cobb, 
of  Boston,  from  their  article  in  the  April,  1904,  purnber  of  the  "  Annals  of  Surgery.") 


INJURIES    OF    THORACIC   VISCERA. 


195 


Injuries  of  the  Thoracic  Viscera. 

These  may  be  divided  into  two  classes: 

1.  The  non-penetrating  or  subcutaneous. 

2.  Penetrating. 

The  first  group  includes  those  following  the  application  of  a  crushing 
force,  whether  appHed  in  a  circumscribed  manner,  such  as  follows  a 
blow  or  a  fall  upon  some  object,  as  well  as  in  those  where  the  force  acts 
diffusely,  e.  g.,  crushing  between  two  objects,  etc. 

The  second  group  includes  those  following  the  use  of  sharp  or 
cutting  weapons  or  the  use  of  firearms  of  whatever  nature. 


Lung- 


Right 
Lungr 


D 


ml 

Fig.  127. — Cross-section  of  Thorax  (Diagrammatic)  to  Show  Mode  of  Proddction  of  Pneumothorax 
OR  Hemothorax  and  of  Subcutaneous  Emphysema  as  a  Result  of  Fractures  of  the  Ribs. 
ID,  The  arrow  accompanying  these  letters  shows  the  mode  of  action  of  indirect  force  in  producing  frac- 
ture of  the  ribs;  D,  mode  of  action  of  direct  force  in  producing  fracture  of  the  ribs;  P,  pneumothorax  as  a  re- 
sult of  fracture  of  the  rib  and  laceration  of  the  pleura  on  right  side;  A,  extensive  subcutaneous  emphysema  as  a 
result  of  puncture  of  a  lung  by  the  sharp  ends  of  a  fractured  rib  fragment;  the  triple  arrow  shows  the  mode  of 
egress  of  the  air  from  the  punctured  lung  into  the  subcutaneous  tissues;  H,  cross-section  of  heart;  C,  fracture 
at  costo-chondral  junction  without  displacement. 


I.  NON-PENETRATING  OR  SUBCUTANEOUS. 

The  thorax  behaves  like  the  skull  toward  a  crushing  force,  but  pos- 
sesses^ greater  elasticity,  so  that  its  contents  can  alter  their  volume 
and  form  more  readily. 

Death  may  follow  immediately  with  symptoms  of  collapse  without 
even  visible  external  signs,  probably  as  the  result  of  the  injury  of  the 


196 


THOR.\X. 


vagi.  Serious  injuries  are  more  frequent  after  crushing  of  the  thorax 
in  younger  persons  than  in  older,  because  the  elasticity  of  the  ribs  is 
greater  and  the  ribs  offer  less  resistance.  The  majority  of  injuries  of 
this  group  are  accompanied  by  fractures  of  the  ribs  and  sternum. 

Traumatic  Asphyxia. — This  is  a  pecuhar  result  of  severe  thoracic 
compression  (see  Fig.  126).  It  may  be  recognized  by  the  marked 
cyanotic  discoloration  of  the  head,  face,  and  neck. 

This  cyanosis  terminates  ver}^  abruptly  in  the  upper  portion  of  the 

thorax.  It  is  usually  accompanied 
by  fractures  of  the  ribs  and  emphy- 
sema. It  is  due  to  a  dilatation  of 
the  cutaneous  capillaries  of  the  dis- 
colored parts. 

Subcutaneous  Injuries  of  the 
Lungs  and  Pleura. — The  diagnosis 
of  these  complications  occurring 
either  with  or  T\dthout  fractures  of 
the  ribs  depends  on  the  appearance 
of  the  signs  of  pneumothorax  or 
hemothorax,  hemopericardium, 
pleuritis,  emphysema  of  the  subcu- 
taneous tissues,  and  hemoptysis. 

(a)  Subcutaneous  Injury  of  the 
Pleura. — A  moderate  degree  of  em- 
physema, or  of  pneumothorax  vv^hich 
does  not  increase,  or  the  presence  of 
a  dry  pleuritic  friction  rub  is  indic- 
ative of  an  injury  of  the  pleura. 
If  the  intercostal  or  internal  mammar}'  arteries  are  injured,  there  are 
evidences  of  hemothorax. 

One  can  make  a  probable  diagnosis  of  pleural  injur}^  alone  from  the 
presence  of  a  slight  degree  of  emphysema  and  of  pneumothorax  which 
rapidly  subsides  or  from  the  friction  sound  alone.  At  times,  injuries 
of  the  pleura  wiU  cause  no  symptoms.  The  emphysema  can  be  recog- 
nized by  the  peculiar  crackling  or  crepitating  sensation  obtained  upon 
palpating  the  skin. 

(b)  Subcutaneous  Injury  of  the  Lungs. — Subcutaneous  injuries  of 
the  lungs  cause  a  high  degree  of  emphysema  of  the  skin  which  rapidly 
spreads  over  the  entire  body  (see  Fig.  loi)  and  may  imperil  life.  In 
addition,  a  pneumothorax  results  which  increases  rapidly  in  degree, 


Fig.   128. — Emphysema    of   Skix   Follouts-o 

Fractuile  oe  the  Ribs  on  the  Right  Side. 

Note  the  puffiness  of  the  face — the  eyes  ahnost 

closed  (Warren). 


NON-PENETRATING    OR   SUBCUTANEOUS, 


197 


crowding  the  lung  and  heart  over  to  the  opposite  side.  Rarely  it 
may  become  bilateral. 

Hemothorax  and  hemoptysis  are  also  characteristic  of  subcuta- 
neous lung  injury,  varying  according  to  the  extent  of  the  same  and 
disappearing  gradually. 

All  of  these  signs  of  lung  injury  may  be  absent.  Bloody  sputum 
is  especially  apt  to  be  inconstant.  A  number  of  cases  have  been  re- 
corded where  a  pneumonia  developed  after  a  subcutaneous  injury. 


Displaced 
lung. 


Ileum 


Lower    sur- 
face of 
diaphragm 


Intestine 
passing 
through 
aperture 
in  dia- 
phragm 


Fig.  129. — View  of  Diaphragmatic  Herma  niiii  Diaphragm  Raised  in  Order  to  show  Hernial  Open- 
ing IN  Direction  of  Arrow. 


It  was  quite  locahzed,  but  having  all  of  the  clinical  characteristics  of 
this  disease. 

A  pulmonary  hernia  may  appear  in  one  of  the  intercostal  spaces 
as  a  reducible  swelhng  with  a  tympanitic  note,  becoming  prominent 
on  expiratory  efforts  such  as  coughing.  It  crepitates  distinctly  like 
lung  tissue  while  being  reduced. 

(c)  Subcutaneous  Injuries  of  the  Diaphragm. — These  are  seldom 
recognized  during  life,  being  usually  immediately  fatal.     They  show 


198  THORAX. 

marked  displacement  fsee  Figs.  129  and  130;  of  the  thoracic  viscera 
by  the  abdominal  organs  which  have  escaped  through  the  rent  in  the 
diaphragm.  There  is  usually  great  dyspnea,  cyanosis,  and  a  distur- 
bance of  cardiac  action.  In  addition,  there  is  a  t}T3ipanitic  note  on 
percussion,  bulging  of  the  thorax,  and  gurghng  on  the  injured  side. 
A^omiting  and  symptoms  of  strangulation  may  also  be  present.  In  this 
connection  it  is  well  to  speak  of  the  frequent  association  of  serious 
abdominal  injuries,    especially   of   the   parenchymatous   organs,   with 


Displaced  right 
lung 


^_A^ 


Transverse 
colon 


Coils  of  ileum 
in  thorax 


Diaphragm 


Small   intestine 


Cecum 


Fig.  130. — Another  View  of  Di.ajhr-agmatic  Hernia  shown  in  Fig.  129  with  Dl\phr.^gm  in  Posi- 
tion AS  Found  at  Autopsy. 


crushing  injuries  of  the  bony  wall  of  the  thorax  or  of  the  thoracic  viscera. 
This  association  should  always  be  borne  in  mind  in  the  examination  of 
such  a  case. 

(d)  Subcutaneous  Injuries  oj  the  Pericardium,  Heart,  Blood-vessels, 
Esophagus,  and  Thoracic  Duct. — With  the  exception  of  those  of  the 
pericardium,  these  injuries  are  so  rare  and  rapidly  fatal  that  they 
cannot  be  recognized  during  hfe.  Injuries  of  the  pericardium  without 
external  signs   cause   either  a   dry   pericarditis   or  hemopericardium, 


PENETRATING    INJURIES    OF   THE    THORAX    PROPER.  1 99 

with  the  characteristic  friction  rub  of  the  former  and  the  increased 
area  of  dulhiess  and  other  physical  signs  of  the  latter.  In  addition, 
there  are  always  syncope  and  symptoms  of  collapse. 

Ruptures  of  the  thoracic  portion  of  the  esophagus  are  very  rare 
and  can  only  be  recognized  by  the  resultant  mediastinitis. 

There  are  nine  cases  of  rupture  of  the  thoracic  duct  recorded,  of 
which  eight  were  followed  by  chylothorax. 


2.  PENETRATING  INJURIES  OF  THE  THORAX  PROPER. 

These  may  be  due  to  the  action  of  a  sharp  or  cutting  weapon  or  to 
gunshot  wounds,  and  include  chiefly  injuries  of  the  lungs  and  pleurae. 
As  in  the  subcutaneous  injuries,  the  cardinal  symptoms  are  emphy- 
sema, pneumothorax,  and  hemothorax.  All  of  these  may,  however, 
be  absent. 

Pneumothorax. — This  can  be  recognized  by  the  usual  signs,  viz., 
a  tympanitic  note  on  percussion,  the  absence  of  respiratory  and  voice 
sounds  and  of  vocal  fremitus.  If  it  is  present  upon  the  left  side,  there 
is  displacement  of  the  heart  to  the  right. 

If  the  pneumothorax  is  only  moderate  in  extent  and  disappears 
rapidly,  it  indicates  pleural  perforation  alone  (Fig.  127)  and  is  due  to 
the  entrance  of  air  through  the  wounds. 

If  it  increases  and  becomes  more  tense  in  spite  of  the  external  wound 
being  closed,  it  indicates  a  wound  of  the  lung  which  has  remained  open. 

Hemothorax. — In  every  case  one  must  decide  whether  the  hemor- 
rhage has  occurred  from  the  vessels  of  the  thoracic  wall  (intercostal  and 
internal  mammary  arteries)  or  from  the  lungs. 

{a)  If  from  the  parietes,  the  external  wound  is  situated  over  the  in- 
ternal mammary  artery,  if  the  hemorrhage  is  from  this  artery.  If  it  is 
from  the  intercostal  vessels,  there  is  also  an  external  wound  to  be  found 
bearing  some  relation  to  these  vessels.  In  both  instances  the  diagnostic 
signs  are  the  escape  of  blood  from  the  wound  in  many  cases,  and  the 
presence  of  a  hemothorax. 

(&)  If  the  hemorrhage  is  from  the  lung,  there  is  expectoration  of 
foamy  blood  and  the  signs  of  hemothorax.  If  the  lung  is  adherent  to 
the  chest  wall,  foamy  blood  escapes  from  the  wound.  Hemoptysis 
may  be  absent  if  the  bronchus  is  plugged  or  there  is  no  communication 
of  the  wound  in  the  lung  with  a  bronchus. 

Bilateral  hemothorax  is  usually  fatal.  Pneumothorax  is  often 
combined  with  hemothorax  so  that  there  is  a  combination  of  physical 


200  THOEAX, 

signs  of  the  presence  of  both  air  and  Hquid  in  the  chest,  because  the 
blood  almost  invariably  remains  liquid. 

3.  Emphysema  of  the  Skin. — {a)  If  due  to  a  pleural  wound  alone, 
it  is  only  moderate  in  extent,  and  is  due  to  the  entrance  of  air  through 
the  wound  and  disappears  rapidly. 

(5)  If  it  be  due  to  injury  of  the  lung,  it  is  far  more  marked  and 
constantly  increases.  If  the  lung  is  adherent  it  may  become  excessive 
and  cause  death  from  asphyxia  unless  relief  is  obtained  by  artificially 
producing  a  collapse  of  the  lung. 

4.  Dyspnea  and  Cyanosis. — These  are  only  marked  if  there  is  a 
high  degree  of  pneumothorax  or  hemothorax. 

5.  Prolapse  of  lung  through  the  external  wound  is  positive  proof  of 
a  pleural  injury.     It  is  more  marked  during  coughing  or  expiration. 

6.  The  secondary  comphcations  of  pleural  and  pulmonary  injuries 
are  pneumonia  and  empyema.  These  are  more  frequent  after  pene- 
trating than  non-penetrating  injuries.  The  hemorrhagic  infiltration 
of  the  lungs  favors  the  localization  of  microorganisms,  especially  of  the 
pneumococcus. 

Penetrating  Injuries  of  the  Heart  and  Pericardium.— Just 
as  in  the  case  of  similar  injuries  of  the  thoracic  cavity  proper  and  of  the 
abdominal  cavity,  it  is  impossible  to  make  a  diagnosis  of  the  perfora- 
tion of  a  viscus,  from  the  position  of  the  external  wound  alone, 
although  its  location  over  a  viscus  is  of  some  value.  The  wound  may 
be  at  some  distance  from  the  heart,  as  in  gunshot  wounds. 

In  the  case  of  injuries  of  the  heart  we  place  more  value  upon  the 
accompanying  general  and  local  signs. 

In  the  majority  of  cases  there  is  unconsciousness  immediatelv 
after  the  accident,  probably  due  to  shock,  since  the  same  symptoms  ap- 
pear after  injuries  of  the  heart  without  external  wound.  Accompanying 
this  primary  syncope,  and  especially  to  be  noticed  after  consciousness 
has  been  restored,  are  the  symptoms  of  collapse  due  to  internal  hem- 
orrhage. The  pulse  is  very  feeble  and  irregular;  at  times  it  is  scarcely 
to  be  felt.  There  is  marked  anemia.  The  local  signs  of  value  in  diag- 
nosis are  those  of  the  accompanying  hemopericardium  and  pneumo- 
pericardium.    In  general,  one  may  speak  of  three  classes  of  cases : 

{a)  Those  associated  with  ■  a  wound  in  the  lung.  In  these  the 
prominent  symptom  is  pneumopericardium.  This  may  or  may  not  be 
associated  with  hemothorax  or  pneumothorax.  The  heart  sounds  are 
to  be  heard  as  if  at  a  distance  and  there  is  a  tympanitic  note  replacing 
the  normal  area  of  cardiac  dullness.  If  there  is  a  hemothorax  there 
are  signs  of  internal  hemorrhage  and  dullness  over  the  lung.     In  such 


INFLAMMATORY  PROCESSES    OF    THE    THORACIC    WALL.  20I 

cases    there    is    considerable    anemia,    marked    collapse,    and    feeble 
pulse. 

(b)  Those  of  the  heart  alone  with  escape  of  blood  into  the  pericar- 
dial cavity.  These  give  rise  to  all  of  the  physical  signs  of  hemopericar- 
dium,  accompanied  by  very  feeble  and  irregular  pulse,  cyanosis,  dyspnea, 
and  moderate  anemia.  The  area  of  cardiac  dullness  is  increased  and 
one  hears  a  splashing  sound  due  to  the  heart  beating  in  the  fluid  which 
surrounds  and  interferes  with  its  action.  This  splashing  gradually 
disappears  as  the  pericardial  cavity  fills  up. 

(c)  This  third  class  of  cases  is  characterized  by  the  escape  of  blood 
externally  through  the  wound  in  the  chest  wall.  The  blood  will  be 
red  or  blue  according  to  whether  the  wound  is  in  the  right  or  left  heart. ^ 
In  these  cases  there  are  marked  collapse,  signs  of  hemorrhage  (pallor, 
rapid,  very  feeble  pulse),  and  irregular  heart's  action.  There  is  also 
a  slight  increase  in  cardiac  dullness  and  no  hemothorax. 

The  diagnosis  of  whether  the  heart  has  been  penetrated  or  not  may 
be  made  from  considering  the  location  of  the  wound,  the  general 
symptoms,  and  the  physical  signs  of  pneumopericardium  or  hemoperi- 
cardium  associated  or  not  with  those  of  pneumothorax  or  hemothorax. 

Penetrating  Wounds  of  the  Diaphragm. — These  are  usually 
associated  with  gunshot  or  stab  wounds  of  the  thorax  and  abdomen,  and 
a  diagnosis  cannot  be  made  until  the  wound  has  been  explored. 


Acute  and  Chronic  Inflammatory  Processes  of  the  Tho- 
racic Wall. 
of  the  skin  and  subcutaneous  tissues. 

Furuncles  are  apt  to  appear  on  the  back  of  the  chest,  and  may 
become  quite  large,  especially  over  the  scapulae,  forming  large  carbun- 
cles which  extend  quite  deeply  in  the  subcutaneous  tissues.  One  must 
always  bear  in  mind  the  possibility  of  diabetes  in  patients  who  suffer 
from  these  large  or  recurrent  carbuncles. 

Acute  phlegmon  of  the  subcutaneous  tissue  of  the  thoracic  wall 
is  quite  rare.  It  may  occur  by  extension  from  suppuration  of  the 
axillary  lymph-nodes.  The  infection  travels  rapidly  in  the  connective 
tissue  lying  between  the  skin  and  pectoralis  major  muscle  and  in  that 
lying  beneath  the  latter.  There  is  general  tenderness,  induration, 
and  redness,  accompanied  by  signs  of  septicemia. 

Tertiary  Syphilis. — One  of  the  favorite  scats  of  gummatous  ulcera- 
tions is  on  the  skin  of  the  back.     They  can  be  recognized  by  their  irregu- 

'Niebert:   "Philadelphia  Medical  Jour.,"  Mar.  3,  1902. 


202 


THORAX. 


lar  serpentine  form,  clear-cut,  sharp  edges,  and  deep  character.  Their 
multiple  occurrence,  lack  of  induration,  and  the  absence  of  indurated 
lymph-nodes  or  lymph-vessels  will  exclude  a  carcinoma  (see  Fig.  131). 

Actinomycosis  of  the  skin  and  subcutaneous  tissue  of  the  thorax 
is  secondary  to  that  of  the  lungs  or  mammary  glands.  In  the  former 
case  one  finds  indefinite  symptoms  of  pulmonary  consolidation,  with 
subsequent  breaking  dowm  of  lung  tissue  associated  with  multiple  areas 
of  softening  and  sinus  formation  in  the  skin.  In  that  secondary  to 
actinomycosis  of  the  breast  there  are  also  sinuses  of  long  duration 
leading  to   the    parenchyma   and   discharging   pus.       The    condition 

greatly  resembles  tuber- 
culosis, but  there  is  a 
more  brawny  infiltra- 
tion of  the  skin,  and  ex- 
amination of  the  pus 
shows  the  actinomyces. 
Both  sarcoma  and  car- 
cinoma of  the  skin  of 
the  thorax  may  occur  as 
primary  affections  upon 
the  site  of  a  previous 
pigmented  mole  (see 
Fig.  132). 


AFFECTIONS  OF  THE 
BONY  THORAX. 

Acute  Osteomyeli- 
tis of  the  Ribs.— This 

is  a  very  rare  affection  of 
the  ribs,  especially  the 
form  which  is  due  to  the 
organisms  producing  the  same  condition  elsewhere,  viz.,  the  staphylo- 
cocci. It  may  occur  as  a  complication  of  an  acute  infectious  disease,  such 
as  influenza,  pneumonia,  and  typhoid,  either  during  the  course  of  the  dis- 
ease or  following  it.  It  is  most  frequent  at  or  near  the  costochondral 
junction.  In  tlie  form  which  follows  the  above  acute  infections  the  diag- 
nosis may  be  made  from  the  history  of  the  infectious  disease,  the  local 
findings,  and  the  constitutional  disturbances.  These  two  latter  are 
swelling,  acute  pain,  and  tenderness  over  the  rib,  more  or  less  fever,  and 
leukocytosis. 


Fig.  131. — Tertiary  Syphilitic  Ulcerations  of  Back. 

Note  the  characteristic  sharp  edges  and  punched-out  condition  of 

the  ulcers,  and  the  tendency  to  oval  outline. 


AFFECTIONS    OF   THE    BONY   THORAX. 


203 


Acute  Osteomyelitis  of  the 
Sternum. — This  condition  is 
very  rare,  only  nine  cases  having 
been  reported.  The  symptoms 
are  those  of  violent  epigastric 
pain,  high  fever,  delirium,  and 
local  inflammatory  symptoms, 
such  as  tenderness  and  edema. 
The  pus  may  collect  in  the  an- 
terior mediastinum,  which  is  the 
direction  of  least  resistance;  if 
so,  the  condition  is  very  apt  to 
be  overlooked. 

Tuberculosis  of  the  Ribs 
or  Sternum. — This  form  of 
bone  disease  is  comparatively 
frequent  in  the  ribs  and  ster- 
num. Its  course  is  so  insidious 
that  the  patients  often  seek  sur- 
gical advice  onlv  when  a  tubercular 


# 


CL 


'^ 


Fig.  133. — Lateral  View  of  Patient  shown  in 
^FiG.  132,  WITH  Primary  Carcinoma  of  the 

Srin  (J). 

The  dotted  lines  {CL)  indicate  the  nodules  of 
a  carcinomatous  lymphangitis  passing  toward  the 
axillary  lymph-nodes  which  could  be  distinctly  felt 
through  the  skin. 


Fig  132. — Primary  Carcinoma  of  the  Skin  of  the 
Thorax  (T);  CL,  Carcinomatous  Lymphan- 
gitis, THE  Nodules  of  which  Could  be  Dis- 
tinctly Palpated  through  the  Skin. 


abscess  or  sinus  has  formed.  It  may 
at  times  be  difficult  to  determine  the 
point  of  origin  of  a  tubercular  ab- 
scess, owing  to  the  fact  that  it  is  apt 
to  gravitate  so  that  its  external  open- 
ing is  found  at  some  distance  from 
the  original  focus.  Upon  the  back 
such  an  abscess  may  lie  beneath  the 
fascia  and  greatly  resemble  a  lipoma 
(see  Figs.  134  and  135),  fluctuation 
being  very  indistinct.  In  the  scap- 
ular region  tuberculous  abscesses 
both  from  the  posterior  ends  of  the 
ribs  and  from  the  dorsal  vertebrae 
may  appear  gradually  without  any 
inflammatory  symptoms  or  pain. 
The  following  are,  in  general,  the 
diagnostic  features  of  tubercular  af- 
fections of  the  ribs  and  sternum. 
The  appearance  of  a  thickening  of 
the  rib  or  sternum  is  accompanied 
by  slight  pain  and  by  elevation  of 


204 


THORAX, 


temperature.  In  the  more  advanced  stage,  in  which  the  cases  are  usually 
seen,  a  soft,  fluctuating  swelling  is  found,  devoid  of  inflammatory  symp- 
toms and  distributed  over  one  or  several  ribs  and  their  interspaces. 

Such  tubercular  abscesses  must  be  differentiated  from  lipomata 
and  subcutaneous  abscesses  due  to  a  spontaneously  perforated  empyema 
(see  page  212).     Lipomata  are  generally  lobulated,  the  skin  can  be 

moved  over  them,  and 
they  are  freely  mov- 
able as  a  whole  upon 
the  thorax.  They  do 
not  fluctuate. 

An  abscess  result- 
ing from  a  spontan- 
eously perforated  em- 
pyema occurs  oftenest 
in  children  and  usu- 
ally around  the  nipple, 
but  may  take  place 
anywhere.  There  is 
fever  and  the  physical 
signs  of  an  effusion  in- 
to the  pleural  cavity 
(see  Fig.  141). 

When  single  or 
multiple  sinuses  have 
formed,  the  diagnosis 
presents  no  difflcul- 
ties.  There  is  a  his- 
tory of  a  long- contin- 
ued, almost  painless 
illness,  with  constant 
discharge  of  a  thin  yellowish  pus.  The  edges  of  the  sinus  are  hned  by 
flabby  or  even  caseous  granulations. 

Tubercular  abscesses  may  form  upon  the  inner  side  of  the  rib  as 
peripleuritic  abscesses  or  collections  of  pus,  and  be  difficult  to  differen- 
tiate from  encapsulated  empyema  except  from  the  history  of  an  acute 
infection  with  high  temperature. 

In  elderly  people  a  tuberculosis  of  the  rib  may  begin  as  a  marked 
enlargement  and  induration  of  the  rib  which  greatly  resembles  a  malig- 
nant growth  until  softening  with  accompanying  fluctuation  occurs. 
If  tuberculosis  occurs  in  the  sternum  and  causes  a  retrosternal 


Fig.  134. — Direct  Posterior  View  of  Patient  shown  in  Fig. 
13s,  showing  the  extent  of  the  tumor,  due  to  a  tuber- 
CULOUS Abscess,  Secondary  to  Dorsal  Spondylitis,  and 
Simulating  a  Lipoma. 


AFFECTIONS    OF   THE    BONY   THORAX. 


205 


collection  of  pus,  the  pressure  symptoms  may  resemble  those  of  a 
retrosternal  tumor  (see  page  220)  or  of  an  aneurysm,  but  there  is  often 
an  edema  over  the  sternum.  The  pus  generally  escapes  at  the  left  of 
the  sternum  at  the  level  of  the  second  rib,  but  may  gravitate  downward 
toward  the  recti  muscles  of  the  abdomen. 

Syphilis. — The  form  of  syphilis  of  the  bones  of  the  thorax  that  is  of 
greatest  interest  is  the  gumma.  It  occurs  as  a  flat,  often  exquisitely 
sensitive,  localized 
thickening  of  the  peri- 
osteum of  the  ribs  and 
sternum  greatly  re- 
sembling the  softer 
varieties  of  the  peri- 
osteal sarcoma.  When 
the  process  has  affect- 
ed the  bone  itself,  ne- 
crosis results  and  a 
sinus  is  present  in  the 
skin  from  which  a  ten- 
acious and  homogen- 
eous pus  escapes.  At 
this  stage  it  may  be 
thought  to  be  tuber- 
culosis. In  the  latter, 
there  is  generally  a 
softer  fluctuating 
swelling  preceding  the 
formation  of  the  sinus. 
The  pus  from  a  tuber- 
cular abscess  is  cas- 
eous and  flocculent 
and   the  granulations 

are  flabby  and  often  cheesy.  There  is  also  an  absence  of  the  history 
and  of  the  manifestations  of  syphilis  elsewhere.  The  latter  is  also  true 
of  those  periosteal  gummata  resembling  sarcoma  of  the  ribs  or  sternum, 
i.  e.,  before  they  are  broken  down.  They  also  present  more  inflamma- 
tory symptoms,  such  as  tenderness,  etc.,  than  a  sarcoma,  are  slower  in 
growth,  and  rapidly  respond  to  antisyphilitic  treatment. 


Fig.   135. — Lateral  View  of   Patient   as   shown   in   Fig.    134, 
Suffering  from  Tubercular  Abscess  of  Scapular  Region, 
Simulating  a  Lipoma. 
The  dotted  line  shows  the  extent  of  the  pseudo-fluctuation. 


2o6  THORAX. 

TUMORS  OF  THE  CHEST  WALL. 

In  making  a  diagnosis  of  a  thoracic  swelling  which  can  be  either 
seen  or  felt  externally  the  follo^^ing  points  must  be  considered: 

1.  How  long  has  the  swelling  existed? 

2.  Does  it  belong  (a)  to  the  skin  or  the  bony  thorax,  or  (h)  arise 
from  within  the  chest  and  protrude  externally  ? 

3.  The  consistency  and  other  characteristics,  such  as  rate  of  growth, 
etc. 

The  various  forms  of  tumors  or  swellings  which  occur  are: 

I.  From  THE  Skix  Itself.  2.  From  the  Boxy  Thoe_a.x. 

Pigmented  moles.  Enchondromata  of  the  ribs  or  sternum. 

Single  or  multiple  soft  fibromata.  Sarcomata  of  the  ribs  or  sternum. 

Sarcoma  and  carcinoma.  Secondary    carcinomata    of    the    ribs    or 
Capillary    and    cavernous     hemangio-  sternum. 

mata.  Abscesses  due  to  tuberculous  ribs  or  ster- 
Lymphangiomata  (capillary  and  cystic).  num. 

Lipomata.  Gummata  of  the  ribs. 

3.  From  within  the  Thor.a^:. 

Aneur3'sms. 
.    Gravitation  abscesses  due  to  dorsal  spondylitis. 
Spontaneously  perforated  empyemata. 
Actinomycotic  abscesses. 

The  characteristics  of  the  swellings  due  to  tubercular,  syphilitic, 
or  actinomycotic  infection  were  considered  on  pages  203  and  205.  All 
of  the  tumors  in  the  above  lists  except  the  angiomata  appear  after 
birth.  The  tymphangiomata  and  hemangiomata  do  not  differ  from 
the  same  forms  of  new-growths  elsewhere  and  have  been  fully  de- 
scribed in  the  preceding  chapter.  They  may  at  times  attain  an  enor- 
mous size,  involving  the  entire  one-half  of  the  thorax. 

Pigmented  moles  can  be  recognized  by  their  bro^A^lish  color  and 
occurrence  in  the  skin.  They  are  stationary'  in  growth  until  a  sarcoma- 
tous or  carcinomatous  change,  when  they  increase  in  size  rapidly, 
forming  very  malignant  growths  (see  Fig.  132). 

Fibromata  also  occur  in  the  skin^  eithei-  as  a  single  pedunculated, 
often  very  large  tumor,  or  as  multiple  fibroma  molluscum,  smaller 
tumors  (see  Figs.  376,  377).  They  are,  as  a  rule,  quite  soft,  and  slow  in 
growth  unless  a  sarcomatous  change  occurs. 

Sarcoma  of  the  skin  is  not  frequent.  It  can  be  recognized  by  its 
rapid  growth  and  firmer  consistency  than  ordinary  fibromata. 

Lipomata  almost  always  occur  in  the  subcutaneous  tissues  of  the 
back  and  sides  of  the  chest.     The  skin  is  movable  over  them  and  the 


TUMORS    OF   THE    CHEST    WALL. 


20"; 


tumors  sho^Y  characteristic  lobulation.  When  deeply  situated  they 
may  give  rise  to  a  sense  of  pseudo-fluctuation  resembling  that  of  an 
abscess.  They  may  grow  rapidly  at  times,  giving  rise  to  very  large 
tumors. 

The  most  frequent  tumors  of  the  bony  thorax  are  periosteal  sar- 
comata of  the  ribs.  Sarcomata  of  the  sternum  are  much  rarer. 
Sarcomata  can  be  recognized  by  the  history  of  a  rapid  growth,  by  their 
attachment  to  the  ribs,  and  their  firm  consistency.  They  may  at  times 
spread  over  the  inter- 
spaces to  adjacent  ribs 
(Fig.  136).  They  are 
seldom  attached  to  the 
skin,  which  is  usually 
freely  movable  over 
them. 

Pure  enchondroma- 
ta  of  the  ribs  are  infre- 
quent, but  chondrosar- 
comata  are  almost  as  fre- 
quent as  the  pure  perios- 
teal variety  of  sarcoma. 
They  give  rise  to  large 
and  very  firm  tumors, 
which  enlarge  the  rib 
rapidly  in  all  directions. 
They  may  grow  into  the 
spinal  canal  and  com- 
press the  spinal  cord. 

Secondary  tumors 
of  the  ribs  or  sternum 
belong  either  to  the  car- 
cinomata   or  sarcomata. 

The  diagnosis  may  be  made  from  the  sudden  appearance  of  a  growtli 
whose  consistency  varies  according  to  the  nature  of  the  primary  growth. 
This  latter  should  always  be  searched  for  in  such  cases. 

Of  swelhngs  or  tumors  arising  from  within  the  thorax,  the  ones 
of  chief  interest  are  aneurysms  and  pulmonary  hernia.  The  former 
can  be  recognized  by  the  appearance  of  a  prominence  over  the  upper 
portion  of  the  sternum  (see  Figs.  138  and  139)  or  over  the  second  rib 
which  pulsates  in  the  expansile  manner  characteristic  of  aneurysms  in 
general,  and  produces  a  distinct  murmur  on  auscultation.     They  must  be 


Fig.  136. — Periosteal  Sarcoma  Invol\ing  Fourth,  Fipth, 
Sixth,  Seventh,  and  Eighth  Ribs. 

The  arrow  points  to  the  prominence  caused  by  the  tumor  when 
viewed  in  an  antero-posterior  direction. 


THORAX. 


differentiated  from  those  rare  abscesses  of  tlie  sternum  or  rib  which  have 
a  transmitted  pulsation.  Their  characteristic  situation,  the  presence  of 
murmurs,  expansile  pulsation,  and  the  confirmatory  A;-ray  examination 
render  a  diagnosis  easy  in  the  majority  of  cases. 

A  pulmonar}'  hernia  may  appear  as  an  oval  swelling  in  an  inter- 
space following  a  history  of  injury.  It  becomes  more  prominent  on 
coughing,  but  can  be  reduced,  giving  rise  to  a  crackling  sound  or 

crepitation.  Quite  rarely  in- 
terthoracic  lipomata  penetrate 
the  chest  wall  and  appear  ex- 
ternallv. 


EMPYEMA. 
Pus  in  the  pleural  cavity 
may  be  due  to  a  number  of 
causes. 

Causes.- — (a)  It  may  fol- 
low pneumonia.  It  is  then 
due  to  the  pneumococcus,  and 
is  called  a  metapneumonic  em- 
pyema. 

(b)  It  may  occur  secondary 
to  other  joci  oj  suppuration  0} 
the  lung  or  neighboring  viscera. 
This  form  is  caused  by  the 
Streptococcus  pyogenes.  The 
infection  extends  to  the  pleura 
either  by  direct  continuity  of  tissue  or  by  means  of  the  lymphatics.  It 
is  in  one  of  these  ways  that  empyema  follows  an  abscess  or  gangrene  of 
the  lung,  a  subphrenic  or  hepatic  abscess,  an  appendicitis,  a  perforation 
of  the  esophagus,  or  a  penetrating  wound  of  the  thorax.  The  Strepto- 
coccus is  often  associated  with  the  Staphylococcus  aureus.  These  two, 
or  other  organisms  such  as  the  typhoid  or  colon  bacillus,  may  cause  an 
empyema  independently. 

(c)  Tuberculous  Empyema.— This  is  a  ^-ariety  which  is  due  to  the 
tubercle  bacillus,  either  alone  or  in  conjunction  with  streptococci  or 
staphylococci. 

The  diagnosis  of  empyema  may  be  from : 

1.  The  histor}'. 

2.  The  chnical  course. 


Fig.  137.- — Capillary  Angioha  of  ^LAiniAHY  Region 
OF  Infakt. 


EMPYEMA. 


209 


3.  The  physical  examination  and  resuhs  of  exploratory  puncture. 

History. — There  is  either  an  accompanying  pneumonia,  or  the  his- 
tory may  show  that  it  followed  a  preceding  pneumonia  or  serofibrinous 
pleurisy  or  one  of  the  acute  infectious  diseases,  hke  typhoid,  measles, 
scarlatina,  etc.  It  may  also  follow  some  septic  pulmonary  or  abdomi- 
nal process  or  there  may  be  the  history  of  a  trauma.  There  often  may 
be  a  coexisting  pulmonary  tuberculosis. 

Clinical  Course. — The  symptoms  may  have  appeared  in  a  slow, 
insidious,  or  in  an  abrupt  manner.     In  the  former  there  is  gradually 
increasing  pallor  and  emacia- 
tion.    In  the  acute  onset  the 
disease  begins  with  a  chill  and 
great  prostration. 

After  the  disease  has  begun 
there  is  a  fever  of  a  continuous 
type  in  the  ordinary  purulent 
form  and  of  an  irregular  type 
in  the  putrid  empyemata.  In 
the  latter  there  are  frequent 
chills  and  remissions  of  tem- 
perature. There  is  marked 
leukocytosis.  Repeated  pro- 
fuse sweats  are  quite  charac- 
teristic. 

Physical  Examination  (see 
Figs.  140  and  141). — Inspec- 
tion shows  diminished  move- 
ment on  the  side  of  the  effu- 
sion. In  children  there  is 
often  bulging  of  the  intercostal 
spaces.  In  left-sided  empyema 

the  apex-beat  is  seen  to  be  displaced  to  the  right  beyond  the  right  sternal 
•line.     In  children  there  is  often  a  lateral  cur^•e  of  the  dorsal  spine,  the 
convexity  being  toward  the  diseased  side. 

Palpation. — There  is  absence  of  vocal  fremitus  except  in  children, 
where  the  transmission  of  the  voice  sounds  is  frequently  retained. 
The  apex-beat  can  be  felt  to  be  displaced  a  variable  distance  to  the 
right  in  a  left-sided  empyema. 

Percussion. — If  the  exudate  Kes  between  the  two  adjacent  lobes 
of  a  lung  (interlobar),  or  between  the  base  of  a  lung  and  the  diaphragm 
(diaphragmatic  form),   it  cannot  be  recognized  by  percussion.     The 
14 


Fig.    138. — Side  View  of  Case  of  Aneurysm  of  the 
Arch  of  the  Aorta. 


2IO 


THORAX. 


area  of  dullness,  or  rather  flatness  (the  note  being  of  a  wooden  quality), 
may  be  circumscribed  (Fig.  142)  or  diffuse,  according  to  whether  the 
empyema  is  encapsulated  or  not.  In  the  diffuse  variety  the  upper 
line  of  dullness  is  either  S-shaped  or  flat.  The  liver  and  spleen  are  dis- 
placed downward. 

Auscultation. — Over  the  area  of  dullness  the  breath  and  voice 
sounds  are  absent,  while  above  it  they  are  harsh  and  exaggerated. 
In  children  both  of  these  signs  are  apt  to  be  misleading  because  the 

respiratory  murmur  and  voice 
sounds  are  often  increased, 
even  tubular  in  quality. 

Exploratory  Puncture. — 
This  method  is  of  great 
value.  The  needle  should 
be  of  medium  length  and 
about  twice  the  caliber  of  an 
ordinary  hypodermic  needle. 
It  should  be  inserted  into  the 
center  of  the  area  of  dullness 
in  an  encapsulated  empyema. 
In  the  diffuse  variety  it  is  best 
introduced  in  the  sixth  inter- 
space in  the  midaxillary  or 
postaxillary  line  and  the  pis- 
ton gradually  withdrawn.  If 
the  examination  is  seen  to  be 
negative  when  the  piston  has 
been  withdrawn  one-third  of 
the  way,  the  needle  should 
be  pulled  out.  One  will  often 
find  a  drop  of  pus  in  the  tip  of  the  needle  when  none  has  been  drawn 
into  the  barrel  of  the  syringe  (Fig.  143). 

Differential  Diagnosis  of  Empyema. — {a)  From  Pneumonia. — 
The  onset  of  pneumonia  is  always .  sudden,  accompanied  by  a  chill, 
the  fever  is  higher,  there  is  more  cyanosis  and  dyspnea,  and  the  sputum  is 
rusty.  The  dullness  is  not  so  wooden  in  character,  there  is  less  resis- 
tance, and  vocal  fremitus  is  not  absent.  In  some  cases  the  auscultatory 
signs,  especially  in  children,  may  be  very  confusing.  In  such  patients 
the  voice  and  respiratory  sounds  are  either  plainly  to  be  heard  or  are 
even  exaggerated.  The  only  way  in  which  such  cases,  in  both  adults 
and  children,  can  be  differentiated  from  empyema  is  by  exploratory 
puncture. 


Fig.  139. — Front  View  op  Same  Case  shown  in  Fig. 


EMPYEMA. 


211 


Fig.  140. — Area  op  Flatness   in   Left-sided   Diffuse,  that   is, 
Non-encapsulated,  Empyema. 

A,  Location  of  apex-beat.  The  dotted  area  above  it  indicates 
the  area  of  dullness  of  the  displaced  heart.  The  numerals  refer  to 
the  respective  ribs. 


The  same  holds  true  for  cases  of  circumscribed  dulhiess  in  children  due 
to     slowly     resolving 
bronchopneumonia 
with  persistent  fever, 
pallor,  and  sweats. 

(b)  From  Tumors 
and  Hydatids  of  the 
Lung  and  Pleura. — 
Both  of  these  give  rise 
to  dullness  with  sup- 
pression of  respiratory 
sounds.  The  percus- 
sion note  is,  however, 
even  flatter  than  in 
empyema  and  there  is 
greater  resistance. 
There  is  also  no  fever 
or  sweats  and  an  ex- 
udate, if  present  as  the 
result  of  the  tumor,  is 
hemorrhagic  in  char- 
acter. 

(c)  Hepatic  and  Right-sided  Subphrenic  Abscesses. — These  give  rise 

to  dulhiess  and  ab- 
sence of  voice  and  res- 
piratory sounds  in  the 
lower  portion  of  the 
pleural  cavity.  The 
area  of  dulhiess  is, 
however,  quite  local- 
ized (see  Fig.  163)  or 
does  not  extend  very 
high.  There  is  a  his- 
tory of  preceding  ab- 
dominal infection  and 
the  liver  is  displaced 
dovniward  far  more 
than  is  the  case  in  an 

Fig.  141.— Area  of  Flatness  in  a  Case  of  Diffuse,  that  is,  Non-  empyema,      i  lie  SCptlC 

encapsulated.  Empyema  OF  THE  Right  Pleural  Cavity  SVmptOmS       are       alsO 
L,  Area  of  liver  dullness,  merging  above  into  the  flatness  of  the  empyema.  1 1  -1-1 

The  ribs  are  indicated  on  the  left  side  by  numerals.  USUaliy  mOrC  marKCQ. 


212 


THORAX. 


The  pus  from  a  heptic  abscess  is  chocolate  colored;  that  from  an 
empyema,  yelloAA'. 

In  left-sided  subphrenic  abscesses  the  dullness  is  often  most  marked 
at  the  back  of  the  chest. 

An  empyema  may  spontaneously  rupture  through  the  pleura  and 
form  a  subcutaneous  fluctuating  tumor  (see  page  204)  from  the  third 
to  the  sixth  interspace,  usually  the  fifth.  When  near  the  heart  the 
tumor  may  pulsate.  On  the  other  hand,  the  pus  may  escape  along 
the  peripleuritic  connective  tissue  and  gravitate  toward  the  abdominal 
or  lumbar  muscles,  appearing  as  an  abscess  in  these  regions,  simulating 
one  following  disease  of  the  spine  or  a  perinephritic  abscess. 


Fig.  142. — Location  of  Flttid  ix  Diffuse  axd  Ekcapsulated  Thoracic  Empyzmata,  as  seen  k  Cross- 
section  (DiAGRAililATIc). 
DE.  The  black  area  represents  the  distribution  of  the  pus  in  a  diffuse  empyema;  CE,  black  area  represents 
the  distribution  of  the  pus  in  an  encapsulated  empyema;   H,  cross-section  of  heart;   RL,  right  lung;  LL,  left 
limg  (compressed) 


TUMORS  OF  THE  PLEURA. 

Carcinoma,  en  chondroma,  endothelioma,  and  rarely  lipomata  are 
obsen^ed  in  the  pleura.  The  carcinomata  and  sarcomata  are  almost 
always  secondary  to  the  same  growths  in  the  ribs,  mammary  glands, 
mediastinal  hmiph-nodes,  and  lungs.  The  hpomata  may  arise  from 
the  mediastinal  or  subpleural  fat  and  project  into  the  pleural  cavity. 

The  diagnosis  of  tumors  of  the  pleura  is  very  difficuh,  unless  there 
is  demonstrable  primary  tumor.  The  s}-mptoms  simulate  those  of  a 
pleural  or  pericardial  effusion,  and  they  are  frequently  accompanied 
by  more  or  less  exudate,  which  is  hemorrhagic  in  character,  but  may 
be  serous.  A  tumor  can  be  suspected  if  there  is  increased  resistance 
when  the  needle  is  introduced  and  bv  the  absence  of  fever.     In  the  mahg- 


PULMONARY   ABSCESS,    GANGRENE,    AND    BRONCHIECTASIS. 


213 


nant  forms  of  pleural  tumors  there  is  rapidly  increasing  cachexia; 
the  effusion,  if  present,  reaccumulates  rapidly;  and  there  are  often 
severe  intercostal  neuralgic  pains  due  to  the  tumor  growing  through 
the  intervertebral  foramina. 

PULMONARY  ABSCESS,  GANGRENE,  AND  BRONCHIECTASIS. 
The  lesions  that  present  themselves  for  diagnosis  may  be  classified 
as  follows:  (a)  Acute  simple  abscesses;  (b)  chronic  simple  abscesses, 


/     / 


Fig.  143. — Method  of  Performing  Exploratory  Puncture  of  the  Pleural  Cavities. 
After  careful  disinfection  of  the.  area  of  skin  through  which  the  puncture  is  to  be  made,  the  needle  should  be 
inserted  through  either  the  sixth  interspace  in  the  anterior  midaxillary  or  posterior  axillary  lines.  This  method 
can  be  carried  out  with  the  patient  either  Ij'ing  down  or  sitting  up,  preferably  the  former.  Before  inserting 
the  needle,  the  skin  should  be  pressed  against  thc-tissues  of  the  interspace,  in  order  to  prevent  any  slipping  and 
striking  of  the  bone  with  the  point  of  the  needle. 


with  or  without  bronchiectasis;  (c)  acute  gangrenous  abscesses;  and 
(d)  chronic  putrid  abscesses,  with  bronchiectasis.  As  to  the  symp- 
tomatology of  pulmonary  abscess,  the  following  is  usually  the  history: 
A  patient  who  has  had  pneumonia,  for  example,  of  the  lower  lobe 
will  have  his  crisis,  the  physical  signs  begin  to  clear  up,  the  temperature 


214 


THOEAX. 


drops,  when  suddenly  the  temperature  goes  up  again,  becomes  of  a 
remittent  type,  and  the  sputum  becomes  more  purulent.  There  may 
be  a  distressing  cough,  accompanied  by  the  expectoration  of  pus  in 
large  quantities.  Some  elastic  fibers  may  be  present  in  the  sputum, 
but  are  rare.  There  are  often  paroxysms  of  coughing,  with  expecto- 
ration of  several  ounces  to  a  cupful  of  pus.     If  the  abscess  cavities 


Fig.  144. — Method  of  Counting  the  Ribs  for  the  Purpose  of  Determining  the  Level  of  Fluid,  etc., 

LN  THE  Pleural  Cavity. 
One  usually  begins  by  palpating  the  angulus  Ludovici  or  prominence  at  the  junction  of  the  first  and  second 
portions  of  the  sternum,  that  is,  of  the  manubrium  and  gladiolus.     By  passing  the  fingers  outward  one  strikes 
the  second  rib.     From  this  point  do\\Ti  the  remainder  of  the  ribs  can  be  readily  counted. 


do  not  communicate  with  a  bronchus,  there  is  but  little  expectoration. 
There  is  in  all  cases  emaciation,  loss  of  appetite,  and  a  rapid  decline 
in  strength.  If  the  abscess  becomes  chronic,  there  may  be  recurrent 
attacks  of  fever,  with  a  great  deal  of  expectoration.  Physical  exami- 
nation is  rather  disappointing.  There  are  few  cases  in  which  there 
are  cavity  signs  present.  This  is  due  either  to  the  indirect  manner  in 
which  the  abscess  communicates  with  the  bronchus,  or  to  the  fact  that  it 


Fig.  144  a. — Illustration  of  Pulmonary  Gangrene  Close  to  Surface  of  Pleura. 

Note  the  greenish  color  of  the  wall  of  the  area  of  pulmonary  gangrene  and  the  trabeculas 

of  surviving  lung  septa  traversing  the  wall  of  the  cavity. 


PULMONARY   ABSCESS,    GANGRENE,    AND    BRONCHIECTASIS.  21 5 

does  not  open  into  one  at  all.  The  pulmonary  lesions  following  pneumonia 
are  most  frequently  in  the  lower  lobes,  and  this  is  of  some  aid.  There 
are  no  typical  physical  signs  of  abscess  of  the  lung  owing  to  the  fact 
that  the  cavities  (whether  due  to  abscess,  gangrene,  or  bronchiectasis) 
may  be  near  the  surface  or  quite  deeply  situated,  and  may  or  may 
not  communicate  with  a  bronchus.  Dullness,  decreased  respiratory 
murmur,  vocal  resonance,  and  fremitus  are  present  in  the  majority 
of  cases,  but  there  may  be  bronchial  breathing.  The  most  valuable 
sign  is  the  presence  of  rales — large,  moist  ones,  not  infrequently  metallic 
in  character.  Another  striking  feature  is  the  variability  of  the  physical 
signs— once  dullness,  then  a  tympanitic  note  over  the  same  spot.  A 
pus  cavity,  surrounded  by  aerated  lung  tissue  and  not  communicating 
with  a  bronchus,  gives  no  auscultatory  phenomena.  Clubbed  fingers 
develop  quite  early,  as  do  also  pressure  symptoms  on  the  heart,  liver, 
and  spleen.  If  after  a  pneumonia  the  fever  either  does  not  disappear 
or  begins  again  a  few  days  after  a  crisis,  and  the  sputum  and  breath 
become  fetid,  and  the  sputum  divides  itself  into  the  characteristic 
three  layers,  gangrene  must  be  suspected.  This,  as  Frankel  has  shown, 
is  a  frequent  sequel  of  influenza  pneumonia.  In  the  sputum  of  gan- 
grene one  can  usually  find  elastic  fibers.  In  bronchiectasis  following 
pneumonia  the  sputum  may  be  fetid  at  times,  but  the  odor  is  not  so, 
penetrating  and  there  are  no  elastic  fibers.  The  physical  signs  of 
both  pulmonary  gangrene  and  bronchiectasis  are  usually  the  same  as 
those  of  abscess.  In  a  patient  with  bronchiectasis  there  is  usually  a 
history  of  long- continued  expectoration,  with  the  sudden  expectoration 
of  large  quantities  of  pus,  at  times  a  cupful.  This,  however,  is  not 
characteristic,  for  the  same  may  be  true  of  chronic  simple  abscess. 
There  is  said  to  be  more  mucus  in  the  sputum  of  a  bronchiectasis, 
but  if  there  are  cavities  in  the  lung  tissue  due  to  ulcerations  of  a  bron- 
chiectasis there  may  be  just  as  much  pus  as  from  a  simple  abscess  and, 
if  there  is  associated  gangrene,  just  as  much  fetor  as  in  a  gangrene. 
The  frequency  of  hemoptysis  in  cases  of  a  gangrenous  process  is  due 
to  the  fact  that  the  vessels  are  more  apt  to  pass  exposed  through  the 
cavity,  owing  to  the  more  rapid  destruction  of  tissue. 

(a)  The  previous  history  of  pneumonia,  particularly  an  influenza 
pneum.onia,  and  (b)  the  character  of  the  sputum — which  in  an  abscess 
is  of  a  chocolate  color  and  occasionally  contains  elastic  fiber,  and  in 
gaitgrene  becomes  more  and  more  offensive  as  the  case  progresses — 
are  important  points  in  the  estabhshment  of  a  diagnosis.  In  bron- 
chiectasis the  sputum  is  at  first  odorless,  but  usually  becomes  foul 
from  the  stagnant   pus.     The  localization   of  the  abscess  is   always 


21 6  THOEAX. 

difficult;  aspiration  is  dangerous,  the  physical  signs  are  not  reliable 
and  are  often  misleading.  The  x-Y&y  is  only  of  confirmator}'  value, 
as  it  shows  chiefly  thickened  areas  of  lung,  and  should  not  be  absolutely 
relied  upon.  When  it  shows  a  shadow  at  the  same  point  where  the 
physical  signs  are  present,  it  is  of  value.  The  latter  may  mislead  one 
as  to  the  seat  of  the  abscess,  and  is  of  no  service  in  distinguishing 
between  single  and  multiple  foci. 


ECHINOCOCCUS  OF  THE  LUNGS. 

This  localization  of  the  echinococcus  is  next  in  frequency  to  that 
of  the  liver  and  occurs  oftenest  in  the  right  lower  lobe.  Chnically  it 
greatly  resembles  a  pleuritic  effusion,  and  a  diiferential  diagnosis  can 
be  made  only  by  examination  of  the  fluid  obtained  by  explorator}'' 
puncture.  In  the  case  of  echinococcus  it  is  clear,  water}',  and  contains 
the  characteristic  hooklets  of  the  worm. 

Only  large  cysts  or  a  collection  of  smaller  ones  produce  any  symp- 
toms. These  cause  dullness  which  is  more  irregular  than  that  of 
an  effusion.  There  are  signs  of  pressure,  such  as  dyspnea,  displace- 
ment of  the  heart  and  liver,  pain,  especially  upon  lying  on  the  diseased 
side.  There  is  often  enlargement  of  the  cutaneous  veins  over  the 
cyst  and  widening  of  the  intercostal  spaces. 

There  is  no  rise  in  temperature  unless  the  cyst  is  infected  and  has 
ruptured.  Then  the  signs  greatly  resemble  those  of  a  cavity  in  the 
lower  lobes. 


ACTINOMYCOSIS  OF  THE  LUNGS  AND  PLEURA. 
This  disease  may  appear  clinically  in  one  of  two  forms: 

(a)  A  peribronchial  pneumonic  form  in  which  the  symptoms  re- 
semble those  of  tuberculosis.  The  diagnosis  can  only  be  made  if  the 
ray  fungus  is  found  in  the  sputum. 

(b)  A  second  cHnical  form  in  which  the  disease  has  extended  into 
the  pleural  ca\dty  and  chest  wall.  The  signs  are  those  of  a  pleurisy 
but  without  effusion,  or  there  is  a  board-like  infiltration  of  the  chest 
wall  followed  by  the  appearance  of  subcutaneous  abscesses.  The 
spontaneous  perforation  of  the  latter  leaves  sinuses  which  may  be 
confused  with  those  of  tuberculosis.  The  finding  of  the  ray  fungus 
will  clear  up  the  diagnosis. 


SUPPURATIVE    PERICARDITIS.  217 

Tumors  of  the  Lungs. 

Tumors  of  the  lungs  are  almost  always  malignant,  and  rarely 
primary. 

Secondary  growths  are  usually  disseminated  over  both  lungs,  while 
primary  ones  occupy  the  greater  part  of  one  lung.  The  diagnosis  of 
the  presence  of  secondary  tumors  depends  upon  (a)  the  appearance 
of  pleuritic  pain;  (b)  cyanosis;  (c)  dyspnea;  (d)  cough,  and  (e)  the 
signs  of  effusion  following  a  year  or  more  after  a  primary  tumor  of 
the  breast,  limbs,  etc.,  has  been  diagnosed  as  such.  A  primary  growth 
of  the  lungs  shows  unilateral  involvement  with  signs  of  consolidation, 
but  the  tactile  fremitus  is  absent  and  the  breath  sounds  are  diminished 
in  intensity.  There  is  prune-juice  expectoration,  emaciation,  and 
enlargement  of  the  adjacent  cervical  lymph-nodes. 


Suppurative  Pericarditis  (Pyopericardium). 

Fluids,  whether  pus  or  serum,  lying  within  the  pericardial  sac  cause 
the  same  physical  signs. 

Purulent  pericarditis  may  (a)  be  pyemic  in  origin,  or  (b)  follow  a 
penetrating  wound  of  the  pericardium,  or  (c)  arise  by  extension  from  a 
neighboring  focus. 

Perforation  of  the  thoracic  wall  may  occur,  giving  rise  to  sinuses 
or  abscesses. 

Purulent  pericarditis  occurring  during  the  course  of  a  septicopyemia 
cannot  be  recognized  except  from  the  physical  signs,  or  if  attention 
has  been  called  to  the  heart  by  the  accelerated,  feeble,  and  often  irregular 
pulse. 

In  the  other  varieties  there  are  usually  repeated  chills  accompanied 
by  high  fever  and  sweats.  The  pulse  and  respiratory  rate  are  rapid. 
Cases  occasionally  occur  with  normal  pulse,  temperature,  and  respira- 
tion. When  an  exudate  previously  serous  becomes  purulent,  there  are 
chills  with  considerable  fluctuations  of  temperature,  pulse,  and  respira- 
tion, accompanied  by  sweats,  a  rapid  emaciation,  and  leukocytosis. 

The  physical  signs  of  pyopericardium  are  bulging  of  the  precordial 
space,  especially  in  children,  the  apex-beat  cannot  be  felt,  the  area  of 
cardiac  dullness  is  greatly  increased  and  pear-shaped,  the  base  being 
downward,  and  the  heart  sounds  are  very  weak. 

Exploratory  puncture  of  the  fourth  and  fifth  left  interspaces,  one 
inch  from  the  sternal  margin,  shows  the  presence  of  pus.  The  xipho- 
costal  route  is,  however,  used  by  many,  the  needle  being  inserted  at 


2l8 


THORAX. 


the  right  xiphocostal  angle.  There  is  no  danger  of  wounding  the 
hver  or  diaphragm,  because  these  are  depressed  in  pyopericardium 
(Fig.  145)- 

Affections  of  the  Mediastinum. 

Two  conditions  of  this  region  frequently  require  to  be  recognized 
by  the  surgeon  as  well  as  by  the  physician.  These  are  inflammatory 
affections  and  tumors. 


Fig.  145. — MzTHOD  or  Performing  Exploratory  Punxtcre  of  the  Pericardium,  in  Order  to  Deter- 
mine THE  NATURE  OF  A  PERICARDIAL  EXUDATE. 

The  patient  can  be  thus  explored  either  in  a  recumbent  or  upright  position.     The  needle  should  be  inserted  in 
either  the  fourth  or  fifth  interspaces  close  to  the  sternum,  great  care  being  taken  not  to  insert  it  too  deeply. 


INFLAMMATORY  PROCESSES. 

These  may  be  either  acute  or  chronic.  The  foiTiier  are  caused  by 
the  ordinar}^  pyogenic  organisms  and  arise  by  extension  of  suppurative 
processes  in  the  neck  or  rarely  from  an  acute  osteomyelitis  of  the  ribs 
or  sternum.  From  the  neck,  pus  may  reach  the  mediastinum  either 
along  the  carotid  sheath  or  along  the  previsceral  or  retrovisceral  spaces. 
The  symptoms  of  acute  mediastinitis  are  severe  pain  and  a  feehng  of 
oppression  behind  the  sternum  radiating  to  the  shoulders.  This  is 
accompanied  by  fever,  chills,  sweats,  rapid  pulse,  and  other  signs  of 


TUMORS    OF    THE    MEDIASTINUM.  219 

a  septic  infection.  The  diagnosis  may  be  made  from  tliese  symptoms, 
taken  in  conjunction  with  the  history  of  a  preceding  infection  in  the 
adjacent  parts. 

Chronic  ini3ammatory  processes  are  ahnost  always  due  to  tuber- 
culous disease  of  the  bronchial  lymph-nodes  and  are  impossible  to 
recognize  unless  they  rupture  into  the  bronchus,  aorta,  or  esophagus. 


TUMORS  OF  THE  MEDIASTINUM. 

All  tumors  of  the  mediastinum  cause  somewhat  similar  symptoms. 
Their  severity  depends  upon  the  size  and  nature  of  the  growth. 

The  most  frequent  conditions  which  thus  appear  with  signs  of  intra- 
thoracic pressure  are  the  following : 

Bknign  Afpections.  Malignant  Affections. 

1.  Retrosternal  goiter.  i.  Carcinomata. 

2.  Dermoid,  cysts.  2.  Sarcomata. 

3.  Echinococcus  cysts.  3.  Hodgkin's  disease. 

4.  Aneurysms  of  the  arch  of  the  aorta. 

5.  Fibroma. 

The  diagnosis  in  the  case  of  the  malignant  affections  depends  (a) 
upon  the  greater  rapidity  with  which  the  symptoms  of  pressure  appear, 
(b)  the  more  frequent  association  of  pleuritic  effusion,  and  (c)  in  many 
cases  the  history  of  primary  growths  situated  elsewhere  in  the  body. 

The  symptoms  in  general  of  mediastinal  tumors  are: 

1.  Engorged  veins  on  the  anterior  and  lateral  portions  of  the  thorax, 
sometimes  accompanied  by  cyanosis  and  edema  of  the  skin  (see  Fig.  146). 

2.  A  marked  dyspnea,  associated  often  with  a  harsh,  brassy  cough. 

3.  Symptoms  of  pressure  on  the  recurrent  laryngeal  nerves  cause 
abductor  paralysis  of  one  or  both  vocal  cords,  usually  the  left. 

4.  Dysphagia  through  pressure  on  the  esophagus. 

5.  Dullness  over  the  upper  portion  of  the  sternum  or  adjacent 
portion  of  the  thorax  (Fig.  146). 

6.  In  some  cases  the  x-yslj  shows  a  distinct  shadow. 

7.  The  heart  and  lungs  may  be  displaced. 

8.  There  may  be  a  bulging  which  may  or  may  not  pulsate.  If 
it  does,  it  has  the  forcible  expansile  pulsation  of  an  aneurysm  (Fig.  138). 

9.  Palpation  of  the  suprasternal  notch  and  of  the  deep  cervical 
nodes  may  confirm  the  suspicion  of  a  tumor. 

When  an  aneurysm  has  not  eroded  the  chest  wall  it  may  be  almost 
impossible  to  differentiate  it  from  a  tumor.  The  cyanosis  and  venous 
enlargement  are  more  marked  in  tumor  and  these  symptoms  are  more 


220 


THORAX. 


progressive.  The  most  valuable  signs  of  aneurysm  are  the  diastolic 
shock  to  be  felt  and  often  heard  over  the  sac,  and  the  radiating  pains 
to  the  arms  and  neck. 

Dermoid  or  echinococcus  cysts  may  occasionally  be  recognized  by 
finding  hairs  or  booklets  respectively  in  the  sputum.  A  case  of  der- 
moid cyst  has  been  recently  reported  by  Senn  in  which  the  diagnosis 
was  made  by  finding  hair  in  the  sputum. 


Foreign  Bodies  in  the  Air  Passages. 

The  diagnosis  of  foreign  bodies  in  the  larynx,  trachea,  or  bronchi 
depends  (a)  upon  the  history,  (b)  upon  the  appearance  of  certain  symp- 
toms of  disturbances 
in  function,  and  (c)  the 
results  of  examination 
with  the  r^f-ray,  the 
lar3Tigoscope,  and  the 
bronchoscope  (Fig. 
91). 

In  the  majority  of 
cases  there  is  a  history 
of  the  aspiration  dur- 
ing an  inspiratory 
effort  of  one  of  four 
varieties  of  foreign 
bodies. 

(a)  Round  or 
conical  bodies — e.  g., 
coins,  buttons,  tin 
whistles,  and  bullets. 

(b)  Sharp  bodies, 
as  pins,  needles,  tacks, 
and  splinters. 

(c)  Vegetable  substances  which  swell,  such  as  seeds  or  beans. 

(d)  Vegetable  substances  which  do  not  swell,  as  wheat,  .etc. 

The  symptoms  vary  greatly.  In  some  cases  there  are  frequent 
attacks  of  asphyxia.  Especially  is  this  the  case  with  the  first  class 
referred  to  and  in  the  initial  period.  In  other  cases  these  attacks  of 
suffocation  may  be  absent.  If  the  body  lodges  in  the  right  bronchus, 
as  is  most  often  the  case,  there  is  a  diminution  or  even  complete  loss  of 
respiratory  sounds  and  movements  on  the  same  side.     Over  the  point 


Fig.  146. — Location  of  Area  of  Dullness  in  jVIediastinal  Tumor 
AND  OF  Prominence  in  Aneurysm  of  the  Ascending  Arch 
OF  THE  Aorta. 

I,  Area  of  dullness  over  manubrium  in  a  case  of  sarcoma  of  the 
mediastinum.  The  outlines  running  toward  it  represent  the  dilated 
veins  of  the  skin  of  the  thorax.  2,  This  figure  is  placed  to  the  left  of  the 
most  frequent  seat  of  prominence  due  to  aneurysm  of  the  ascending 
portion  of  the  arch. 


INFLAMMATORY   PROCESSES. 


221 


of  its  arrest  sibilant  and  sonorous  rales  may  be  heard.  Sharp  bodies 
at  times  cause  localized  pain,  while  larger  obstructing  bodies  cause  a 
sense  of  pressure.  Cough  is  quite  frequently  present  and  the  expec- 
toration may  be  bloody  from  erosion  of  the  bronchi. 

After  noting  the  history  and  the  symptoms  an  examination  should 
be  conducted  with  the  laryngoscope.  If  this  results  negatively  an 
x'-ray  picture  is  taken.  If  the  latter  is  also  negative  the  patient  should  be 
anesthetized  and  the  Killian  bronchoscope  employed  to  find  the  loca- 
tion of  the  foreign  body. 

In  the  absence  of  a  history  one 
must  at  times  suspect  the  presence 
of  a  foreign  body  from  the  symp- 
toms of  a  circumscribed  broncho- 
pneumonia or  bronchiectasis  or  ab- 
scess formation  without  other  causes. 


Diseases  of  the  Breast, 
inflammatory  processes. 

These  may  be  of  four  varieties : 
(i)  Acute  puerperal  mastitis,  (2) 
acute  mastitis  of  infants,  (3)  trau- 
matic mastitis,  and  (4)  chronic 
mastitis. 

I.  Acute  Puerperal  Mastitis. — 
This  occurs  most  frequently  during 
the  first  months  of  lactation.  The 
acute  inflammatory  process  may  be 
located  in  one  of  three  places  (see 
Fig.  147) : 

(a)  In  the  subcutaneous  tissue 
of  the  areola. 

(b)  In  the  gland  parenchyma 
proper. 

(c)  In  the  retromammary  space. 
The  diagnosis  of  the  first  named  is  simple.     An  area  of  redness 

and  painful  swelling  of  the  areola  occurs  which  is  at  first  hard  and  then 
becomes  soft.  Infection  of  the  gland  proper,  to  which  one  usually 
refers  in  speaking  of  mastitis,  most  often  follows  a  small  painful  fissure 
or  crack  in  the  nipple.  Not  infrequently  the  disease  begins  with  a 
chill;  a  rise  of  temperature  to  103°  or  104°,  and  severe  pain  in  the  breast 


Fig.  147. — Seats  of  Various  Forms  of  Suppura- 
tion IN  Mastitis. 
I,  In  subcutaneous  abscess  of  areola;  2,  large 
parenchymatous  abscess  approaching  surface  of 
breast;  3,  seat  of  suppuration  in  early  stages  of 
ordinary  parenchymatous  mastitis,  showing  how 
infection  is  transmitted  from  nipple  along  milk 
ducts;  4,  retromammary  abscess,  lying  between 
breast  and  pectoraHs  major  muscle;  6,  cross-section 
of  clavicle;  7,  cross-section  of  first  rib  (modified 
from  Duplay). 


222 


THORAX. 


in  a  woman  in  whom  there  is  the  history  of  a  preceding  fissure.  The 
breast  becomes  extremely  tender  to  the  touch  and  the  severe  pain 
radiates  toward  the  axilla. 

In  the  early  stages  there  are  distinctly  indurated  and  usually  multiple 

areas  to  be  felt  in  the 
breast,  which  can  be 
distinguished  from  the 
nodules  due  to  stagna- 
tion of  milk,  or  so-called 
"caking  of  the  breast," 
by  the  more  severe  in- 
flammatory symptoms, 
such  as  pain,  fever,  etc. 
Another  point  of 
differentiation  is  the 
fact  that  massage  and 
proper  support  will  be 
followed  by  speedy  dis- 
appearance of  symp- 
toms in  the  "caked" 
breast,  while  in  the  true 
mastitis  they  persist  and 
increase  in  severity. 

In  puerperal  masti- 
tis, in  addition  to  the 
severe  pain  in  the 
breast,  induration,  and 
rise  of  temperature, 
there  is  a  painful  en- 
largement of  the  pector- 
al and  axillary  lymph- 
nodes  (Fig.  148).  After 
a  few  days  of  the  above 
symptoms  the  indurated 
areas  become  larger  and 
approach  the  overlying 
skin.  This  becomes  red 
and  tender,  and  soon  evidences  of  fluctuation  can  be  obtained,  showing 
that  abscess  formation  has  occurred.  If  after  one  of  these  foci  has 
been  opened  the  temperature  persists,  abscesses  elsewhere  must  be 
present  with  retention  of  pus. 


Fig.  148. — Lymphatics  of  Female  Breast. 
I,  Carcinoma  in  outer  upper  quadrant;  2,  supraclavicular  lymph- 
nodes;  3,  axillary  lymph-nodes;  4,  nodes  along  the  lower  border  of 
pectoralis  major;  5,  nodes  along  the  latissimus  dorsi;  6,  lymphatics 
of  arm.  The  arrow  between  i  and  3  shows  the  direction  of  the  lymph-- 
current  from  the  breast  toward  the  axillary  and  supraclavicular  nodes; 
the  arrow  between  the  breast  and  4  shows  the  direction  toward  the 
corresponding  nodes.  The  arrow  from  6  to  3  sho\vs  direction  of  lymph- 
current  from  arm  infections  toward  the  axillary  nodes. 


INFLAMMATORY   PROCESSES. 


223 


There  are  cases  of  puerperal  mastitis  in  which  a  discharge  of  pus 
continues  from  muhiple  foci  months  after  the  abscesses  have  been 
opened.  These  are  the  result  of  a  venous  congestion  due  to  allowing 
the  breast  to  sag  by  not  being  sufficiently  compressed  and  supported. 

The  retromammary  form  of  acute  mastitis  is  not  frequent.  It 
can  be  recognized  by  the  absence  of  foci  in  the  areola  or  parenchyma, 
although  there  is  marked  swelling  along  the  periphery  of  the  breast, 
accompanied  by  pain  and  high  fever.  Fluctuation  appears  at  the 
lower  margin.  At  times 
chronic  retromammary  ab- 
scesses are  met  with,  due  in 
the  majority  of  cases  to  tu- 
berculosis of  the  ribs. 

2.  Mastitis  Neona- 
torum.— During  the  sec- 
ond to  fourth  week  painful 
enlargement  of  the  breast 
occurs  in  both  male  and 
female  infants.  The  breast 
enlarges  to  the  size  of  a 
walnut,  is  quite  hard  and 
tender.  This  enlargement 
generally  disappears  with- 
in a  short  time,  but  may 
rarely  go  on  to  suppura- 
tion, giving  rise  to  redness 
of  the  surface  and  fluctua- 
tion. 

3.  Traumatic  Masti- 
tis.— After  a  blow  or  fall 
upon  the  breast  of  non- 
pregnant women  the  organ 

becomes  enlarged,  quite  painful,  and  may  be  accompanied  by  slight  rise 
of  temperature.  The  diagnosis  jnay  be  made  from  the  history,  the  local 
tenderness,  and  the  frequent  general  enlargement  and  palpation  of  tender 
indurated  areas  in  the  parenchyma. 

Chronic  Mastitis. — This  condition  is  one  which  has  been  de- 
scribed by  various  writers  under  different  names.  Koenig  has  called 
it  "chronic  cystic  mastitis";  Reclus  describes  it  as  "maladie  cystique"; 
Virchow,  as  "diffuse  fibroma";  others  have  termed  it  "chronic  inter- 


FiG.  149. — Method  of  Palpating  a  Tumor  of  the  Breast 
(Cyst). 


224 


THORAX. 


stitial  mastitis";  and,  finally,  the  term  "diffuse  fibroadenoma"   has 
been  given  to  it. 

From  a  pathologic  standpoint^  there  are  three  types: 

1 .  A  low  grade  of  inflammation  T\ath  desquamation  of  the  glandular 
epitheHum  and  the  formation  of  cysts.  This  is  the  form  described  by 
Koenig  as  a  chronic  cystic  mastitis. 

2.  Those  of  a  more  adenomatous  t}'pe  described  by  Schimmel- 
busch  and  Reclus. 

3.  Transition  cases.     In  these  the  breast  may  show  a  dift"use  fibro- 

adenomatous  condition, 
but  in  certain  areas  a 
malignant  change,  i.  e., 
to  carcinoma,  has  taken 
place.  In  thirty  cases  ex- 
amined microscopically  by 
Greenough^  such  a  malig- 
nant change  had  occurred 
in  three. 

This  condition  occurs 
predominantly  in  women 
who  have  borne  children, 
but  not  nursed  them,  and 
especially  often  just  before 
the  menopause.  It  may, 
however,  occur  in  nulli- 
parae. In  some  cases  there 
is  an  apparent  exacerba- 
tion at  the  time  of  men- 
struation, new  nodules  ap- 
pearing   and    the   breasts 

Fig.   150 — Palpation  of  Supraclavicular  Lymph-nodes  es?  bcCOming  painful,  the  COn- 

THE  Female,  in  Case  of  Suspected  Carcinoma  of  the  ,.,.  i     •  t  •  n 

B^j,As.j._  dition  subsidmg  rapidly  m 

the  menstrual  inter^-als. 
Clinically,  one  can  feel  a  number  of  flat  leathery  nodules  in  one  or 
both  breasts,  which  may  be  quite  sensitive.  The  patients  will  often 
state  that  the  nodules  become  painful  during  the  menses,  accompanied 
by  an  enlargement  of  the  axillary  and  pectoral  lymph-nodes  (Figs.  150 
and  151). 

If  a  cyst  of  any  size  (Fig.  149)  is  present,  it  feels  tense  and  elastic. 

'  Curtis  and  Wood:  "^Medical  News,"  August  13,  1904. 

^Greenough  and  Hartwell:   "Journal  of  Medical  Research,"  June,  1903. 


TUBERCULOSIS    OF    THE    BREAST, 


225 


If  a  number  of  smaller  cysts  have  been  formed  they  feel  hke  beans  or 
shot  (Curtis).  The  principal  affection  from  which  it  must  be  differen- 
tiated is  carcinoma. 

This  question  is  especially  apt  to  arise  if  one  or  more  large  cysts 
have  formed.  The  condition  can  be,  however,  distinguished  from  car- 
cinoma by  the  following  features: 

1.  Chronic  mastitis  is  usually  bilateral,  or  if  not,  there  are  many 
nodules  in  a  single  breast  which  are  frequently  quite  tender. 

2.  The  nodules,  if 
cystic,  have  a  distinct 
smooth,  rounded  form, 
and  unless  very  tense 
show  fluctuation. 

3.  The  size  and  ten- 
derness of  the  nodules 
often  increase  during 
menstruation. 

4.  The  axillary  nodes, 
if  enlarged,  are  soft  and 
tender. 

5.  The  progress  of 
the  disease  extends  over 
years,  unless  large  cysts 
are  present. 

There  are  a  few  ex- 
ceptions; for  example: 

1.  Cases  in  which 
there  is  marked  indura- 
tion and  sharp  demarca- 
tion. Fig.  151. — Palpation  of  Axillary  Glands  in  the  Female. 

2.  Cases  in  which  car- 
cinomatous changes  have  already  occurred  (transition  cases),  either  in 
one  of  the  breast  nodules  or  in  the  axillary  nodes  alone. 

In  such  cases  it  is  absolutely  impossible  to  differentiate  between  a 
chronic  cystic  mastitis  and  carcinoma  until  marked  retraction  and 
fixation  of  the  nipple  and  marked  induration  of  the  tumor  and  of  the 
axillarv  nodes  have  occurred. 


TUBERCULOSIS  OF  THE  BREAST. 
Of  100  reported  cases  of  this  rare  condition,  only  65  have  been 
examined  microscopically.     It  involves  the  gland  most  frequently  at 


226 


THOR.\X. 


the  period  of  life  (twenty  to  forty)  of  its  greatest  activity.  The  course 
is  a  very  chronic  one.  It  either  occurs  in  (a)  sl  nodular  form;  (b)  as  a 
cold  abscess;  (c)  confluent  form  fmost  common);  (d)  miliar\\ 

The  diagnosis  is  rarely  made  before  either  an  abscess  has  formed 

or  sinuses  exist.  Usu- 
ally the  case  is  sup- 
posed to  be  a  fibro- 
adenoma in  the  nodu- 
lar form  or  is  diag- 
nosed as  a  chronic 
cystic  mastitis  (espec- 
ially in  the  more  con- 
fluent form)  before 
operation.  Sinuses,  if 
they  exist,  have  the 
typical  bluish  under- 
mined edges  of  tuber- 
cular lesions. 

In  every  case  the 
axillary  lymph-nodes 
are  enlarged,  but  if 
these  are  absent  the 
diagnosis  may  be  very 
difficult. 

Simple  cysts  re- 
sulting from  chronic 
mastitis  are  more  cir- 
cumscribed, fluctuate 
much  sooner,  are  often 
painless,  and  do  not 
enlarge  the  axillary 
nodes.  When  the  cysts 
are  small  and  tender, 
the  dift"erentiation  is 
very  difficult.  In  tu- 
berculosis there  is, 
however,  early  axillary  lymph-node  enlargement. 

From  the  scirrhus  form  of  carcinoma  this  condition  can  be  distin- 
guished by  the  fact  that  tuberculosis  occurs  in  younger  persons,  is  never 
as  indurated,  and  there  are  more  apt  to  be  multiple  nodules. 

From  actinomycosis  it  can  be  distinguished  by  finding  the  ray  fungus 
in  the  yellow  granules  and  by  the  thickened  indurated  skin. 


Fig.  152. — Relation  between  Lyuphatics  of  Femaie  Breast  and 

THOSE  OF  iMEDIASTINClI  AND  LrTER. 

M,  Carcinoma  of  breast,  causing  retraction  of  nipple;  i,  I\inph- 
nodes  of  supracla\'icular  fossa;  2,  cross-section  of  claWcle;  3,  pectoralis 
major  muscle;  5,  lymph-nodes  along  the  internal  mammary  artery; 
A,  aorta;  4,  hmph-nodes  at  bifurcation  of  trachea;  these  may  cause 
dyspnea  and  cough  after  carcinoma  of  breast;  H,  heart,  seen  in  section; 
6,  lymphatics  of  upper  surface  of  liver,  which  receive  the  lymph  from 
the  mediastinal  nodes  through  the  diaphragm;  7,  metastatic  foci  in  the 
liver;  8,  lymph-nodes  at  porta  hepatis;  9,  lymph-nodes,  along  aorta 
(modified  from  Kuttner  and  Duplay). 


BENIGN   NEOPLASMS. 


227 


HYPERTROPHY  OF  THE  BREASTS. 

This  condition  can  be  readily  recognized,  owing  to  the  enormous 
bilateral  increase  in  the  size  of  the  breasts.  It  occurs  most  often  at 
puberty  or  shortly  thereafter.  It  may  be  simulated  by  a  retromammary 
lipoma,  but  this  is  only  unilateral.  The  breast  may  increase  so  rapidly 
in  size  that  within  a  year 
it  increases  ten  to  twenty 
pounds,  or  even  more,  in 
weight,  and  extends  down 
as  far  as  the  knees. 

A  hyperplasia  of  the 
male  breast  occurs  on 
either  one  or  both  sides, 
and  causes  pain  and  dis- 
comfort. ^^M  f 


NEOPLASMS  OF  THE 
BREAST. 

These  are  best  divided 
into  two  great  classes,  the 
benign  and  the  malignant. 
To  the  former  belong  the 
fibroadenoma,  with  its 
special  forms,  the  fibroma 
intracanaliculare,  and  the 
papillary  form. 

To  the  second  or  malignant  group  belong  the  sarcoma  and  carci 
noma.     ' 


Fig.  153. — Retraction  of  Nipple  in  a  Case  of  Carcinoma 

OF  THE  Breast. 

The  arrow  points  downward  toward  the  retracted  nipple. 


BENIGN  NEOPLASMS. 

Fibroadenoma  of  the  Breast. — Pure  fibromata  and  pure  aden- 
omata are  \'ery  rare.  The  majority  of  these  tumors  contain  both 
forms  of  tissue,  but  usually  more  of  the  fibrous  than  of  the  glandular. 

The  chief  diagnostic  points  are: 

(a)  Age.     They  generally  occur  between  twenty  and  thirty. 

(&)  Growth.  As  a  rule,  the  increase  in  size  is  very  slow  and  gradual. 
In  some  cases  they  remain  dormant  for  many  years,  and  then  suddenly 
increase  in  size.  Apparent  recurrence  may  lake  place,  but  these  are 
undoubtedlv  new  tumors. 


228 


THORAX, 


(c)  Mobility,  consistency,  and  form.  They  are  usually  quite 
firm  and  round,  or  oval.  The  larger  they  grow,  the  softer  do  they 
become.  The  nearer  the  skin  they  lie,  the  more  movable  are  they. 
As  a  rule,  they  are  not  painful  and  are  never  as  hard  as  a  carcinoma. 
When  removed,  they  are  found  to  be  distinctly  encapsulated. 

(d)  They  never  cause  retraction  of  the  nipple  or  enlargement  of 
the  axillary  lymph-nodes. 

Even  in  the  unusual  pathologic  forms  of  fibroma  intracanaliculare, 

simple  or  papillary,  the  same 
clinical  signs  above  described 
are  retained. 


MALIGNANT  NEOPLASMS. 

Sarcoma  of  the  Breast. 

- — These  constitute  about  2 
to  8  per  cent,  of  all  breast 
tumors  and  are  usually  of  the 
round -celled  type.  They 
occur  before  the  age  of  thirty, 
and  are  characterized  by  their 
rapid  growth  and  the  early 
ulceration  of  the  overlying 
skin.  The  entire  breast  is 
usually  involved,  causing  it 
to  feel  uniformly  firm.  En- 
largement of  the  axillary 
lymph-nodes  is  not  frequent, 
but  when  present  the  secon- 
dary tumor  attains  enormous 
size. 

Carcinoma  of  the  Breast. — The  best  division  of  this  form  of  neo- 
plasm from  a  clinical  point  of  view  is  into  a  scirrhus  or  hard,  and  a  medul- 
lary or  softer  variety.  Colloid  carcinoma  may  occur,  but  is  relatively 
rare  and  cannot  be  diagnosed  as  such  before  operation.  The  chief 
diagnostic  points  of  carcinoma  are: 

(a)  Age. — The  medullary  form  usually  occurs  in  women  between 
thirty-five  and  fifty-five,  while  the  scirrhus  variety  occurs  after  the  latter 
age.  Carcinoma  more  frequently  affects  the  breast  of  women  who 
have  nursed  children,  or  have  had  infections  or  chronic  cystic  mastitis 
(page  223).  There  is  undoubtedly  a  direct  relation  between  cancer 
of  the  breast  and  trauma. 


Fig.  154. — Anterior  View  of  Case  of  Sarcoma  of  the 
Breast. 
Note  the  enormous  enlargement  of  the  right  breast  (5), 
and  the  large  tumor  of  the  axilla  (AL),  due  to   secondary 
enlargement  of  the  axillary  lymph-nodes. 


MALIGNANT    NEOPLASMS. 


229 


(b)  Location  and  Groivth. — The  disease  usually  begins  as  a  single 
nodule,  most  frequently  in  the  inner  quadrants  of  the  breast.  If  the 
carcinoma  begins  in  the  ducts  instead  of  the  acini,  there  is  early  fixation 
and  induration  around  the  nipple. 

This  duct  or  tubular  form  of  carcinoma  is  the  one  usually  found  in 
the  male.     It   is  less  fre- 
quent   than     the     deeper 
acinous  form  in  the  female 
breast. 

The  carcinomatous 
nodule   is    usually  single. 

The  rate  of  growth  is 
far  more  rapid  than  in  the 
case  of  benign  tumors.  In 
the  medullary  form  this  is 
more  marked  than  in  the 
scirrhus. 

(c)  Mobility,  Consis- 
tency, and  Form. — In  the 
early  stage  the  tumor  is 
hard  and  somewhat  mov- 
able. It  soon  becomes  ad- 
herent to  the  skin  (especi- 
ally around  the  nipple  in 
the  scirrhus  form)  and  to 
the  underlying  pectoral 
muscle  (Fig.  152).  In  the 
medullary  form  the  tumor 
is  much  softer  than  in  the 
scirrhus-form.  Ulceration 
of  the  overlying  skin  may 
occur  at  an    early    stage. 

At  first  the  tumor  is  more  or  less  rounded  and  can  be  distinctly  outlined. 
Later  it  becomes  nodulated  and  diffuse. 

(d)  Condition  of  the  Nipple  and  Regional  Lymph-nodes. — In  the 
scirrhus  more  frequently  than  in  the  medullary  form  the  nipple  is  both 
fixed  and  retracted.  Ulceration  may  occur  quite  early  at  this  point 
(Fig.  153).     Pain  is  an  early  and  marked  symptom  in  carcinoma. 

There  is  early  enlargement  of  the  axillary  and  less  often  of  the 
supraclavicular  lymph-nodes  (Figs.  148,  150,  and  151). 

A  systematic  examination  of  these  regions,  as  well  as  of  the  liver,  if 


Fig.  155. — Edema  of  the  Right  Arm  Due  to  Compression 
OF  Axillary  Veins,  Two  Years  after  Operation 
FOR  Carcinoma  of  the  Breast. 

Note  the  great  difference  in  size  between  the  right  and  left  arms. 


230 


THORAX. 


palpable,  should  be  made  (Figs.  150  and  151)  for  evidence  of  lymph- 
node  and  visceral  metastasis.  The  carcinomatous  lymph-nodes  are 
very  hard  and  often  adherent  to  each  other. 

(e)  Complications. — In  addition  to  the  early  cachexia,  cancer  of 
the  breast  may  produce  metastases  in  the  following  places: 

1.  In  the  mediastinal  lymph-nodes,  causing  cough  and  dyspnea 
(see  Fig.  152). 

2.  In  the  lymphatics  of  the  skin  of  the  breast. 

The  skin  of  the  entire  front  of  the  chest  has  a  board-like  consistency 
and  has  been  called  "cancer  encuirasse"  (armor- like  cancer). 

3.  Metastases  in  the  lungs,  liver,  pleura,  and  brain. 

4.  Osseous  metastases.  If  in  the  long  bones,  spontaneous  fractures 
may  occur  after  the  most  trivial  injury.  If  the  deposit  occurs  in 
the  spine  or  skull,  symptoms  of  pressure  upon  the  spinal  cord  or  brain 
occur  when  there  has  been  no  suspicion  of  a  metastasis.  A  so-called 
paraplegia  dolorosa  is  quite  characteristic. 

5.  Edema  of  the  hand  (Fig.  155)  from  pressure  of  carcinomatous 
lymph-nodes  on  the  axillary  vessels. 


DIFFERENTIAL  DIAGNOSIS  OF  TUMORS  OF  THE  BREAST. 

Chronic  Cystic  Mastitis.   Fibroadenoma.  Carcixoma. 

Age Usually  before  forty,  but       In  young  women.      Generally     over   forty, 

may  occur  before  men-  rarely  before  that  age; 

opause,      often      more  accompanied     by 

painful       and      larger  cachexia, 

during  menses. 
Location     and 

growth Multiple   nodules  in  one      Anywhere.  Usually    in  inner  quad- 

or  both  breasts.     Very  Grow     very  rants.     Grow  rapid- 

slow  growth,  except  in  slowly.  ly. 

large  cysts. 

Mobility Not  movable  in  breast  un-      Freely  movable.      Movable  in  very  earli- 

less  one  or  more  large  est   stage;    later   ad- 

cysts — then   only  mod-  herent  to  skin  or  pec- 

erate  mobility.  toral      muscle     and 

fixed  in  breast. 
Consistency    and 

form Large     cysts     either   are      Not  as  hard  as      Very     hard,     irregular, 

round  and  fluctuate  or  carcinoma;  and  not  demarcated, 

are     elastic.       Smaller  outline  round- 

multiple    nodules    feel  ed  and  sharp, 

like  beans. 
Condition      of 
nipple,      and 

pain Very      rarely      refracted.      No  change.    No      Early   retraction.     Of- 

Tumors  often  painful,  pain,  as  a  rule.  ten  pain,  quite  severe 
especially  at  menses.  and  early. 
Condition   of  ax- 
illary   lymph- 
nodes    and  me- 
tastases  Earlier  enlargement  than      Not  enlarged,  as     Early  enlargement. 

in  cancer.     Tender  and  a  rule.  Induration'  very 

soft.     Often  more  pain-  marked.      Evidence 

ful  during  menses.  of    metastases     (see 

page  230). 


CHAPTER  IV. 

THE  ABDOMEN. 

Affections  of  the  Abdominal  Wall, 
inflammatory  processes. 

Furuncles  of  the  skin  of  the  abdomen  do  not  differ  from  those 
found  elsewhere.  It  is  interesting  to  note  that  they  cause  early  enlarge- 
ment of  the  inguinal  lymph-nodes  which  rapidly  disappears  as  soon 
as  the  furuncle  is  incised  and  drained. 

Subcutaneous  suppuration  is  usually  secondary  to  an  infected 
wound  or  to  some  more  deeply  seated  infective  process.  There  is  more 
or  less  induration,  so  that  it  is  difficult  to  detect  fluctuation.  There  is 
also  superficial  pain,  redness,  fever, -and  enlargement  of  the  inguinal 
lymph-nodes. 

In  the  abdominal  wall  proper,  suppuration  may  occur  in  a  number 
of  distinct  spaces. 

1.  Within  the  sheath  of  the  recti  muscles  following  typhoid,  or, 
rarely,  an  injury.  The  pus  can  only  spread  as  far  as  the  umbilicus, 
where  it  may  perforate.  The  previous  history,  the  location  of  the 
swelling,  pain,  and  other  inflammatory  signs  render  a  diagnosis  easy. 
The  swelling  is  more  prominent  when  the  patient  lies  down. 

2.  Retromuscular  Suppuration. — The  pus  lies  in  the  loose  connective 
tissue  between  the  individual  muscle  layers  or  between  the  transversalis 
fascia  and  peritoneum.  All  of  these  spaces  communicate  with  each 
other  freely  and  also  with  the  connective  tissue  of  the  pelvis,  iliac  fossae, 
and  retroperitoneal  space.  A  special  space,  known  as  the  prevesical 
or  cavum  retzii,  is  often  spoken  of  as  being  separated  from  the  retro- 
muscular  space  by  a  septum  (see  Fig.  156),  but  such  a  division  is  not 
found  clinically,  pus  in  one  of  these  spaces  spreading  by  direct  contin- 
uity to  any  of  the  others.  'With  the  exception  of  the  rare  cases  of 
idiopathic  suppuration  in  the  prevesical  space,  the  majority  of  the  cases 
of  suppuration  in  the  intermuscular  and  retromuscular  spaces  are 
secondary.  They  may  be  due  to  a  number  of  different  primary  causes, 
which  it  is  well  to  remember  in  making  a  diagnosis. 

(a)  If  prevesical,  to  cystitis  or  diseases  of  the  prostate  or  seminal 

vesicles. 

231 


232 


THE    ABDOMEN. 


(b)  If  around  the  kidney,  it  is  the  result  of  an  infection  of  the  peri- 
nephritic  tissue  following  some  renal  infection  such  as  perinephritis. 

(c)  If  in  the  retroperitoneal  connective  tissue  of  the  iliac  fossa  it 
may  be  due  (a)  to  suppuration  of  the  deep  iliac  lymph-nodes  following 
phlegmon  of  the  thigh  or  an  inguinal  adenitis;  (/S)  to  tuberculosis  or 
osteomyehtis  of  the  pelvic  bones. 

(d)  It  may  be  due  to  disease  of  the  ribs  or  spine  or  to  a  spontane- 
ously perforated  empyema  (empyema  necessitatis). 

(e)  Secondary  to  perforations  of  the  gall-bladder,  intestine,  appendix, 

stomach,  and  cecum. 
This  group  includes 
actinomycosis  follow- 
ing primary  intestinal 
disease. 

(/)  Secondary  to 
infections  of  the  uter- 
us (especially  puer- 
peral) and  of  the  ad- 
nexa.  Puerperal  in- 
fection may  cause  a 
pelvic  abscess  which 
spreads  to  the  connec- 
tive tissue  of  the  iliac 
fossa  and  retroperi- 
toneal space  (see  Fig. 
156). 

(g)  The  pus  may 
collect    in    the   extra- 
peritoneal subphrenic 
tissue  secondary  to  ap- 
pendicitis or  hepatic  abscess.     This  is  comparatively  rare. 

The  diagnosis  in  all  of  these  is  dependent  upon  the  history  and  the 
presence  of  general  and  local  symptoms  of  suppuration. 

Prevesical  abscesses  (see  Fig.  156)  give  rise  to  an  area  of  dullness  of 
oval  form  like  that  of  the  distended  bladder.  There  is  local  pain,  ten- 
derness, and  fever.  When  the  bladder  is  emptied  the  tumor  still  re- 
mains. The  pus  may  rupture  into  the  bladder  or  into  the  intestine. 
The  tumor  can  be  felt  through  the  rectum  or  vagina.  Inquiry  into 
thehistory  will  usually  result  in  finding  a  primary  focus  in  the  bladder, 
the  generative  organs,  the  bones  of  the  pelvis,  or  the  intestine. 

In  all  of  the  other  forms  of  suppuration  within  or  behind  the  abdom- 


FiG.  156. — Location  of  Abscesses  in  Abdominal  Wall,  etc 
R,  Rectum;  U,  uterus;  B,  bladder;  5,  symphysis  pubis;  F,  skin 
and  subcutaneous  tissues;  W,  muscles  of  abdominal  wall;  M,  retro- 
muscular  abscess;  V,  prevesical  abscess;  PP,  preperitoneal  abscess; 
P,  peritoneum;  RP,  retroperitoneal  suppuration  extending  upward 
from  pelvis. 


TUMORS    OF   THE    ABDOMINAL    WALL,  233 

inal  muscles  the  diagnosis  may  be  made  from  the  appearance  of  a  more 
or  less  circumscribed  area  of  induration,  accompanied  by  fever,  pain, 
tenderness,  and  rigidity  of  the  corresponding  portion  of  the  abdominal 
wall.  Careful  search  will  usually  ehcit  the  primary  source  of  infection. 
If  there  is  pus,  or  even  in  the  case  of  a  tumor  in  the  abdominal  wall, 
both  are  more  prominent  when  the  patient  lies  down.  In  the  major- 
ity of  the  forms  of  suppuration  in  or  behind  the  abdominal  wall  the 
diagnosis  can  be  made  from  the  history  of  a  primary  infection,  the  pres- 
ence of  a  circumscribed  or  diffuse  infiltration,  pain,  tenderness,  and 
fever. 

TUMORS  OF  THE  ABDOMINAL  WALL. 

These  may  occur  either  in  the  skin  itself  or  in  the  deeper  layers. 
Those  of  the  skin  are  usually  soft  pedunculated  fihromata  which  vary 
greatly  in  size  and  number.  Their  soft  consistency,  slow  growth,  and 
pedunculation  render  their  recognition  easy  (Fig.  375).  Pigmented  nevi 
also  occur  with  considerable  variation  in  size  and  number.  They  are 
of  a  brownish  color,  slightly  raised  above  the  surrounding  skin,  and 
often  have  long  hairs  growing  from  their  surface. 

Both  soft  fibromata  and  pigmented  nevi  tend  to  become  sarcomatous 
at  times.  Such  a  change  can  be  recognized  from  the  rapid  growth  of 
the  tumor  as  well  as  the  tendency  to  ulceration  of  the  surface.  The 
deeper  forms  of  neoplasms  are  lipomata  and  desmoids.  Lipomata 
occur  as  subcutaneous,  intermuscular,  and  subserous  growths.  The 
two  first  named  may  be  recognized  by  their  soft,  almost  semifluctuating 
consistency,  and  especially  by  their  lobulated  surface,  most  marked, 
as  in  all  Hpomata,  when  the  overlying  skin  is  sHghtly  stretched.  The 
subcutaneous  lipomata  occur  most  frequently  in  the  median  line.  They 
are  also  lobulated,  and  cause  pain,  which  is  often  referred  to  the  stomach. 

They  may  be  differentiated  from  hernias  of  the  linea  alba  or  umbil- 
ical hernia  by  palpation  (Fig.  157).  In  the  case  of  a  hernia  there  is  a 
distinct  thrill  on  coughing  and  the  contents  can  be  reduced  into  the 
abdominal  cavity  unless  they  are  adherent  to  the  sac.  In  such  cases, 
and  when  linea  alba  hemise  become  strangulated,  a  differential  diagnosis 
from  Hpomata  is  almost  impossible  before  operation.  The  occurrence 
of  subserous  hpomata  in  inguinal  and  femoral  hemise  is  frequently 
found  at  operations  for  the  radical  cure  of  these  conditions,  but  they 
are  seldom  recognized  before  operation. 

]^  Desmoids  are  peculiar  forms  of  fibroid  tumors,  occurring  chiefly  in 
women  between  fifteen  and  fifty  who  have  borne  children.  They  rarely 
occur  in  men.     The  majority  are  in  the  front  part  of  the  abdomen 


234 


THE    ABDOMEN. 


below  the  umbilicus.  They  are  oval  in  form  and  vary  in  size  from  a 
hen's  egg  to  that  of  an  adult's  head.  As  a  rule,  they  are  hard,  but  may 
soften  so  that  cysts  are  formed  which  may  be  hemorrhagic. 

They  may  follow  trauma,  laparotomy  or  herniotomy  operations, 
or  the  prolonged  pressure  of  a  belt.  They  may  be  painful,  especially 
at  the  time  of  the  menstrual  period.  The  diagnosis  depends  on  their 
firm  character  (the  softer  cystic  degeneration  being  exceptional)  upon 
the  smooth  surface,  and  the  fact  that  they  grow  in  the  direction  of  the 
corresponding  aponeurosis  or  scar. 


Fig.   157. — Method  of  Determining  the  Presence  of  an  Umbilical  Hernia. 

Two  fingers,  preferably  the  index  and  middle  finger,  of  the  examiner's  hand  are  placed  over  the  umbilical 

region,  and  the  patient  is  asked  to  cough,  when  the  impulse  can  be  distinctly  felt  if  the  hernia  is  present. 


They  may  become  less  prominent  when  the  patient  sits  up  and  can 
be  less  easily  felt  than  when  they  lie  down.  They  do  not  change  their 
position  when  the  patient  is  turned  toward  either  side,  as  intraabdominal 
tumors  do. 

Differential  Diagnosis  of  Desmoids. — They  must  be  differentiated 
from  an  abscess  or  hematoma  of  the  abdominal  wall  and  from  intra- 
abdominal tumors.  A  hematoma  is  gradually  absorbed,  and  an  abscess 
is  more  sensitive  and  is  accompanied  by  fever  and  leukocytosis.  In 
addition,  the  edges  of  an  abscess  are  less  sharp  and  there  is  usually  a 
primary  cause  (see  page  231)  to  be  found. 


CONGENITAL    CONDITIONS. 


235 


From  intraabdominal  tumors  and  encapsulated  exudates  there  is 
great  difficulty  at  times  in  making  a  differential  diagnosis,  especially 
if  they  have  become  adherent  to  the  anterior  abdominal  wall. 

If  such  an  adherent  intraabdominal  tumor  be  due  to  carcinoma  or 
sarcoma,  there  is  accompanying  cachexia  and  the  history  of  a  rapid 
growth  as  compared  to  the  slow  growth  of  desmoids.  Other  forms  of 
intraabdominal  tumors  show  the  characteristics  described  on  page  234. 


IT 

Fig.  158. — Most  Frequent  Conditions  Occurring  in  Connection  with  Meckel's  Diverticulum  (Miles 

F.  Porter). 
5,  Skin;  M ,  abdominal  wall.  I.  Posterior  wall  of  Meckel's  diverticulum  prolapsed  through  umbilicus. 
II.  Hernia  of  Meckel's  diverticulum.  A  coil  of  intestine  is  seen  pushing  the  posterior  wall  of  the  diverticulum 
outward.  III.  Intestinal  obstruction  due  to  Meckel's  diverticulum.  The  latter  is  seen  attached  to  some 
point  in  the  abdominal  cavity  causing  strangulation  of  a  coil  of  intestine  which  had  slipped  beneath  its  point  of 
origin  and  attachment.     IV.  Fistula  at  umbilicus  due  to  patent  Meckel's  diverticulum. 


CONGENITAL  CONDITIONS. 

These  occur  most  often  in  connection  with  Meckel's  diverticulum 
and  the  urachus.  In  the  former,  a  number  of  conditions  are  found, 
as  follows  (Fig.  158): 

(a)  The  diverticulum  may  be  patent  at  the  umbilicus  with  pro- 
trusion of  the  posterior  wall  of  the  gut.  This  may  be  diagnosed  from 
the  presence  of  a  soft  reddish  tumor  covered  externally  with  mucous 
membrane. 

ih)  There  may  be  simply  a  fistulous  opening,  with  reddish  edges, 
from  which  a  few  drops  of  mucus  having  a  fecal  odor  are  discharged 
and  through  which  a  fine  probe  can  be  passed  into  the  intestine. 


236  THE   ABDOMEN, 

(c)  A  hernia  of  the  gut  may  occur  as  a  compHcation  of  the  posterior 
wall  protrusion. 

{d)  The  diverticulum  may  be  large  and  patulous  at  the  umbilicus. 
Such  a  form  can  be  readily  recognized. 

{e)   The  diverticulum  may  rarely  be  converted  into  a  cyst. 

Malformations  in  connection  with  the  urachus  are  much  simpler. 
Here  a  fistula  is  most  often  present  from  which  both  pus  and  urine  are 
discharged.  Cysts  of  the  urachus  occur  in  the  median  line  between 
the  umbilicus  and  symphysis,  and  can  be  suspected  to  be  of  this  origin 
chiefly  from  the  characteristic  median  location.  The  connection  of  a 
fistula  with  the  bladder  may  be  demonstrated  by  injecting  milk  or 
methylene-blue  into  it  and  then  catheterizing  the  patient. 

ABSCESSES  DISCHARGING  THROUGH  THE  UMBILICUS. 
Pus  escaping  from  the  navel  may  have  its  origin  in  a  number  of 
different  sources.  It  may  be  the  result  of  a  prevesical  or  retromuscular 
suppuration  dependent  on  the  various  primary  sources  of  such  infection 
(see  page  231).  In  addition  to  the  causes  in  the  abdominal  wall  itself , 
one  must  think  of  intraabdominal  causes.  In  children  it  is  a  frequent 
point  of  spontaneous  discharge  of  a  tubercular  peritonitis.  Suppurat- 
ing echinococcus  cysts  and  abscesses  resulting  from  perforations  of 
the  various  hollow  viscera,  all  are  apt  to  discharge  through  the  navel. 

TUMORS  OF  THE  UMBILICUS. 

These  may  be  primary  and  secondary.  At  times  the  discovery  of 
the  secondary  growth  at  the  navel  may  be  the  first  sign  of  an  intraab- 
dominal malignant  disease. 

The  primary  tumors  belong  to  both  the  benign  and  mahgnant  forms. 
Of  the  former,  the  most  frequent  are  dermoids  and  sebaceous  cysts, 
which  can  be  recognized  by  their  soft  doughy  consistency  and  slow 
growth. 

The  primary  malignant  tumors  are  almost  always  carcinomata  and 
grow  rapidly,  appearing  either  in  the  form  of  a  cauliflower-like  growth 
with  firm  edges  or  as  an  ulcerating  surface  with  typical  indurated  edges 
and  base.  There  is  also  accompanying  indurative  enlargement  of 
the  inguinal  lymph-nodes. 

The  secondary  tumors  simply  cause  a  hard  tumor  protruding  at 
the  umbihcus,  and  appear  rather  as  the  result  of  a  direct  continuation 
of  a  widespread  peritoneal  dissemination  than  as  a  metastasis.  They 
are  due  in  two-thirds  of  the  cases  to  malignant  disease  of  the  alimentary 


INJURIES    OF   THE    ABDOMINAL    WALLS    AND    VISCERA.  237 

tract  or  liver,  in  the  remaining  one-third  to  that  of  the  ovaries  and 
uterus. 


Injuries  of  the  Abdominal  Walls  and  Viscera. 

Our  views  in  regard  to  the  indications  for  operation  have  changed 
so  rapidly  during  the  past  fifteen  years  that  it  has  greatly  influenced  the 
question  of  diagnosis.  Up  to  that  time  an  exploratory  laparotomy 
was  only  indicated  in  every  suspected  injury  of  the  abdominal  viscera 
if  symptoms  of  peritonitis  had  appeared. 

At  present  more  progressive  surgeons  believe  that  visceral  in- 
juries resulting  from  stab  or  gunshot  wounds,  as  well  as  severe  crushing 
injuries,  should  be  diagnosed  early  enough  to  be  of  aid  in  saving  the 
patient's  life,  i.  e.,  within  the  first  six  to  twelve  hours. 

When  such  a  patient  is  examined  for  the  purpose  of  making  a 
diagnosis,  a  certain  more  or  less  fixed  routine  method  should  be  followed 
in  order  to  ascertain,  as  soon  after  the  accident  as  possible,  whether  a 
viscus  has  been  injured.  Often  such  a  decision  can  only  be  reached 
if  the  patient  is  examined  a  second  or  third  time  in  a  similar  manner 
one  to  two  hours  later. 

The  routine  method  is  as  follows: 

1.  Ascertain  as  accurately  as  possible  the  exact  manner  in  which 
the  accident  occurred. 

2.  General  condition  of  the  patient. 

3.  Results  of  local  examination. 

4.  Symptoms  of  injury  of  particular  viscera. 

Before  discussing  these  in  detail,  it  may  be  stated  that  injuries  in 
which  there  is  no  external  wound  are  just  as  likely  to  produce  serious 
visceral  lesions,  as  those  in  which  there  is  a  cutaneous  wound.  In 
civil  life  the  former  class  is  far  more  frequent  than  the  latter,  and  with 
the  possible  exception  of  those  cases  in  which  there  is  actual  prolapse 
of  viscera  following  the  action  of  some  penetrating  force,  the  diagnostic 
points  of  both  penetrating  and  non-penetrating  wounds  are  the  same, 
so  that  they  will  be  discussed  together. 

I.  History  and  Mode  of  Accident. — In  stab  wounds  it  will  be  of 
confirmatory  value  to  know  the  length  of  blade,  the  relative  positions 
of  victim  and  assailant,  and  the  direction  in  which  the  instrument  was 
thrust  in  if  possible. 

In  gunshot  or  shell  wounds  the  size  of  the  bullet  or  missile  is  of  value. 
It  has  been  found  that  small  bullets  travehng  with  great  velocity  do 
far  less  damage  than    larger   and  more  explosive  ones.     Too   much 


238  THE    ABDOMEN. 

weight  should,  however,  not  be  placed  upon  this  difference,  since 
wounds  of  the  hollow  viscera  may  cause  as  serious  results  after  small 
as  after  large  perforations. 

In  the  case  of  subcutaneous  injury  we  can  divide  them  into  those 
in  which  there  is  perhaps  only  slight  abrasion  or  contusion  externally, 
and  the  graver  cases  in  which  there  is  a  hernial  protrusion.  The 
modes  of  injury  are,  as  in  the  skull,  chiefly  of  three  varieties: 

(a)  A  circumscribed  force  or  one  which  has  come  into  contact  with 
the  abdomen  over  a  limited  area  only.  As  examples  of  this  class  maybe 
mentioned  kicks,  or  a  fall  upon  some  object,  or  a  blow  from  a  tool  hke 
a  hammer,  etc.,  thrown  at  the  lower  portion  of  the  patient's  thorax  or 
over  the  abdomen  proper. 

(b)  A  diffuse  force  or  one  in  which  one  segment  or  the  entire  abdomen 
has  been  compressed  between  two  opposing  forces.  Such  action  fol- 
lows accidents  like  being  caught  between  buffers  or  in  the  wreck  of  a 
building. 

(c)  An  indirect  mode  of  injury  such  as  follows  a  fall  upon  the  feet 
or  the  falling  of  a  weight  upon  the  back. 

2.  General  Condition  of  the  Patient. — There  are  four  classes  of 
cases: 

{a)  Those  with  marked  primary  shock  symptoms  from  which  the 
patient  never  recovers,  death  ensuing  in  a  short  time  after  the  injury. 

(b)  Those  with  marked  primary  shock  symptoms  passing  imper- 
ceptibly into  those  of  internal  hemorrhage,  either  terminating  fatally 
within  a  few  minutes  to  hours,  or  the  signs  of  internal  hemorrhage 
continue  so  that  a  diagnosis  of  the  injury  of  a  viscus  with  escape  of 
blood  can  be  made. 

(c)  Cases  with  practically  no  general  symptoms  and  in  which  the 
suspicion  of  an  abdominal  injury  only  arises  from  the  history  of  the 
mode  of  injury  or  the  gradual  appearance  of  local  signs  indicating 
hemorrhage  or  beginning  peritonitis.  There  are  also  cases  in  which 
the  symptoms  appear  on  the  second  day,  or  even  as  late  as  the  tenth  day, 
from  dislodgment  of  a  clot. 

(d)  Cases  in  which  there  is  apparently  considerable  primary  shock 
which  clears  up  without  any  local  injury  being  discovered.  This 
last  class  is  the  most  puzzling  from  a  diagnostic  point  of  view. 

Under  shock  symptoms  may  be  included   pallor  of  the  skin  and 
visible  mucous  membranes;  rapid,  weak  pulse  and   respiration;  cold, 
clammy  sweat;  stupor  or  unconsciousness;  lowering  of  blood-pressure; 
dilated  pupils;  and  vomiting  immediately  after  the  accident. 

In  making  an  examination  of  the  general  condition  of  the  patient 


INJURIES    OF   THE    ABDOMINAL    WALLS    AND   VISCERA.  23Q 

one  should  note  whether  the  above  symptoms  of  shock  are  present  or 
absent.  In  case  they  are  present  and  persist  for  more  than  a  few  hours, 
one  must  look  for  local  signs  of  injury.  If  the  patient  does  not  react, 
one  must  look  for  some  cause  in  the  abdomen. 

Extreme  pallor,  a  weak,  rapid  pulse  with  but  little  tension,  thirst, 
restlessness,  shallow  respirations,  and  a  decrease  in  blood-pressure, 
as  determined  by  the  Riva  Rocci  instrument,  indicate  internal  hemor- 
rhage. If  such  is  the  case,  it  may  be  impossible  to  distinguish  it  from 
shock  except  by  the  absence  of  unconsciousness,  of  cold,  clammy  skin 
and  dilated  pupils  in  hemorrhage  (see  page  697).  There  are  cases 
in  which  the  symptoms  of  both  shock  and  internal  hemorrhage  appear 
immediately  after  the  accident,  so  that  it  is  impossible  to  distinguish 
between  them  until  some  hours  have  passed  and  the  hemorrhage 
symptoms  predominate.  If  the  condition  is  due  to  hemorrhage  the 
patient  becomes  paler,  more  apathetic  and  somnolent,  the  pulse  gets 
smaller  and  more  rapid  and  the  respiration  shallower,  even  when 
there  is  no  peritonitis  present.  The  writer  has,  on  the  other  hand, 
seen  a  number  of  cases  of  severe  intraperitoneal  hemorrhage  in  which 
the  pallor  was  not  a  noticeable  feature,  the  primary  anemia  having  been 
partially  recovered  from.  These  exceptions  are  particularly  mentioned 
to  emphasize  the  fact,  first,  that  in  some  cases  it  is  almost  impossible . 
to  make  a  diagnosis  before  operation;  and,  secondarily,  that  too  much 
reliance  should  not  be  placed  on  any  one  symptom. 

3.  Local  Signs  of  Injury. — (a)  Examination  of  the  skin  and 
abdominal  wall.  In  the  case  of  penetrating  wounds  the  situation  of 
the  wound  of  entrance  and  of  exit,  if  the  latter  exists,  is  of  some  value 
in  determining  which  structure  has  been  injured. 

In  former  times  great  stress  was  laid  upon  the  fact  that  many  gunshot 
or  stab  wounds  did  not  penetrate  into  the  abdominal  cavity.  At 
present  the  opinion  of  the  majority  of  surgeons  is  that  no  time  should 
be  wasted  in  speculating  whether  or  not  a  missile  or  knife  has  pene- 
trated, but  exploratory  laparotomy  should  be  performed.  Under  no 
conditions  should  a  wound  be  probed  or  enlarged,  however,  until  the 
proper  aseptic  technic  and  surroundings  have  been  secured  in  order  to 
make  a  diagnosis  by  direct  inspection. 

In  injuries  of  the  abdominal  wall  or  viscera  with  but  slight  or  no 
external  signs  one  should  note  the  presence  of  an  accompanying  frac- 
ture of  the  lower  ribs  or  of  cutaneous  hematomata.  In  the  same 
manner  the  presence  of  a  palpable  gap  in  the  abdominal  muscles, 
with  or  without  the  appearance  of  a  swelling  having  all  the  character- 
istics of  a  hernia  (see  page  401),  is  of  value. 


240  THE    ABDOMEN. 

The  most  important  local  signs,  aside  from  those  to  be  seen  or  felt 
externally  in  the  early  hours  (six  to  twelve  hours)  after  either  a  pene- 
trating or  non-penetrating  injury,  are: 

(a)  Muscular  rigidity. 

(b)  Localized  or  diffuse  pain  and  tenderness  on  pressure. 

(c)  Dullness  in  the  flanks  or  above  the  pubes. 

The  muscular  rigidity  is  due  to  a  reflex  contraction  of  the  abdominal 
muscles,  called  the  "defence  musculaire"  by  French  surgeons.  It  is 
one  of  the  most  characteristic  symptoms  and  is  quite  marked  at  an 
early  stage  over  the  injured  viscus.  The  same  is  true  for  the  pain  and 
tenderness  on  Hght  pressure  which  usually  accompany  the  rigidity. 
These  symptoms  are  indicative  either  (a)  of  peritoneal  irritation  due  to 
the  presence  of  blood,  or  (b)  of  peritonitis,  due  to  the  escape  of  bowel 
or  bladder  contents.  This  rigidity  and  tenderness  extend  over  the 
entire  abdomen.  The  steady  increase  in  the  pulse-rate  and  in  the  degree 
of  tympanites,  and  the  onset  of  vomiting,  etc.,  soon  show  the  presence 
of  a  complicating  peritonitis.  If  pain  is  due  to  injury  to  the  abdominal 
wall  alone,  muscular  rigidity  is  never  as  marked. 

In  the  early  hours  after  an  injury,  especially  in  those  cases  in  which 
there  are  practically  no  signs  of  shock  or  internal  hemorrhage,  one  can 
detect  dulhiess  in  the  flanks  or  above  the  pubes.  Such  dullness,  if  it 
changes  to  tympany  when  the  patient  is  turned  upon  the  opposite  side, 
means  free  blood  or  urine  in  the  peritoneal  cavity.  If  the  dullness  is 
only  above  the  pubes  and  does  not  vary  with  change  of  position  it  is 
due  to  an  extraperitoneal  rupture  of  the  bladder  (see  page  243).  Un- 
fortunately free  fluid  can  seldom  be  demonstrated  at  an  early  stage 
owing  to  the  muscular  rigidity.  At  a  later  stage  its  presence  is  obscured 
by  the  tympanites.  The  author  has  found  it  most  often  above  the 
pubes  in  intraperitoneal  hemorrhage. 

4.  Symptoms  of  Injury  of  Particular  Viscera. — A  convenient 
division  of  the  symptoms  of  injury  of  the  individual  viscera  for  the 
purpose  of  diagnosis  is: 

(a)  Those  cases  in  which  symptoms  of  injur}^  of  the  ahmentary 
canal  predominate. 

(b)  Those  in  which  symptoms  of  injury^  of  the  urinary  organs 
predominate. 

(c)  Those  in  which  signs  of  internal  hemorrhage  predominate. 
Symptoms  of  Injury  of  the  Alimentary  Canal. —  Vomiting. — Nausea 

or  vomiting  continuing  for  some  hours  after  the  receipt  of  an  injury 
are  very  characteristic  signs  of  the  presence  of  an  injury  to  the  stomach 
or  small   intestine.     If   the   vomitus   contains  blood,   it   indicates   an 


INJURIES    OF    THE    ABDOMIXAL    WALLS    AXD    VISCERA.  241 

injury  to  the  stomach.  If  the  vomiting  is  bihous  in  character,  a  wound 
of  the  small  intestine  should  be  suspected. 

Obliteration  of  the  Liver  Dullness. — This  sign,  if  present  in  the 
form  of  tympany  replacing  a  normal  hepatic  dullness,  is  of  great  value. 
Unfortunately,  however,  it  is  rarely  present,  so  that  but  little  weight 
can  be  placed  upon  its  absence. 

Presence  of  Evidence  of  Free  Fluid  in  the  Peritoneal  Cavity. — As  was 
stated  above,  the  presence  of  free  fluid  in  sufficient  quantities  to  permit 
of  its  detection  by  percussion  is  so  rare  in  the  early  hours  of  a  stomach 
or  intestinal  injury  as  to  be  of  little  value.  If,  however,  a  changing 
line  of  dullness  in  the  flanks  and  above  the  pubes  can  be  found,  it  is 
indicative  of  such  visceral  perforation.  One  must,  however,  exclude 
the  possibility  of  intestinal  coils  full  of  fluid  feces  or  the  possibility 
of  free  hemorrhage  giving  rise  to  the  same  signs. 

The  most  typical  symptoms  at  an  early  stage  of  gastric  or  intestinal 
perforation  are  the  gradual  rise  in  the  pulse-rate  and  the  presence  of 
an  increasing  leukocytosis.  If  an  increase  in  the  pulse-rate  is  not 
due  to  primary  shock  or  hemorrhage,  such  an  increase  is  strongly 
indicative  of  a  beginning  peritonitis. 

Tympanites. — If  in  a  patient  who  has  sustained  an  injury  of  the 
abdomen  in  any  of  the  modes  above  described  there  is  a  gradual  in- 
crease in  the  distention  of  the  abdomen  and  other  symptoms,  such  as 
inability  to  pass  flatus,  there  can  no  longer  be  any  question  as  to  the 
existence  of  a  perforation.  As  was  stated  above,  in  the  majority  of 
cases  a  diagnosis  made  when  tympanites  is  marked  is  of  comparatively 
little  value  from  an  operative  standpoint,  since  septic  paresis  of  the 
intestines  is  already  well  advanced. 

The  passage  of  blood  in  larger  or  smaller  quantities  with  the  bowel 
movement  is  also  a  positive  sign  of  intestinal  injury.  If  black  and 
tarr\"  in  character,  it  indicates  hemorrhage  high  up  toward  the  stomach 
or  the  duodenum.  If  fresher  in  color  it  indicates  hemorrhage  lower 
down. 

The  pain,  tenderness,  and  rigidity  of  the  abdominal  wall  are  often 
quite  localized  in  gastric  or  intestinal  injur}-.  This  is  especially  true 
of  those  cases  of  appendicitis  which  apparently  seem  to  follow  directly 
upon  the  reception  of  an  injury. 

Symptoms  of  Injury  of  the  Urinary  Organs. — This  includes  injuries 
of  the  kidneys  and  ureter. 

Injury  of  the  Kidney. — If  the  wound  in  the  kidney  communicates 
freely  with  the  general  peritoneal  cavity,  it  produces  the  same  symptoms 
of  internal  hemorrhage  as  those  in  which  there  is  perforation  of  solid 
16 


242  THE    ABDOMEN. 

viscera  like  the  liver  and  spleen,  and  will  be  referred  to  below.  Injury 
of  the  kidney  in  which  there  is  no  such  communication  causes  pain, 
and  not  infrequently,  swelling  over  the  lumbar  region.  The  pain  is 
apt  to  radiate  along  the  ureter  into  the  testis  or  thigh  upon  the  side  of 
the  injury.  There  is  also  tenderness  over  the  kidney  and  considerable 
rigidity  of  the  lumbar  muscles.  The  most  characteristic  symptom, 
however,  of  injury  to  the  kidney  is  the  presence  of  hematuria.  In 
bleeding  from  the  kidney  the  blood  is  intimately  mixed  with  the  urine 
and  accompanied  by  worm-like  clots  which  are  casts  of  the  ureter, 
whose  passage  down  along  the  ureter  cause  the  colicky  pains  just 
spoken  of.  The  hematuria  is,  as  a  rule,  most  marked  just  after  the 
reception  of  an  injury,  gradually  diminishing  in  quantity.     Even  the 


Fig.  159. — Extensive  Destruction  of  Kidney. 
The  organ  is  completely  lacerated.     It  occurred  in  a  case  of  subcutaneous  injury  of  the  abdominal  wall  with- 
out external  sign.     (See  text.) 

symptom  of  hematuria  may  at  times  be  absent,  and  yet  extensive 
lacerations  of  the  kidney  have  occurred,  as  in  the  case  recently  observed 
by  the  author  in  which  there  was  pulpification  of  the  kidney  without 
any  blood  in  the  urine,  as  a  result  of  a  crushing  injury.  The  ureter  was 
blocked  by  a  large  clot  so  that  no  hematuria  occurred.  Fortunately 
such  cases  are  very  rare. 

In  order  to  state  positively  that  hematuria  is  from  the  kidney  the 
bladder  should  be  washed  out  and  some  of  the  irrigating  solution  left 
in  the  bladder.  This  rapidly  becomes  tinged  with  blood  as  the  latter 
escapes  from  the  ureter  and  passes  through  the  catheter  which  has 
been  left  in  place.  In  some  cases  the  above  symptoms  of  injury  to  the 
kidney  may  be  accompanied  by  evidences  of  displacement  of  the  kidney, 
as  determined  by  palpation  of  the  abdomen  (see  Fig.  160). 


INJURIES    OF   THE    ABDOMINAL    WALLS    AND    VISCERA. 


243 


It  is  impossible  to  diagnose  an  injury  of  the  ureter  until  a  tumor 
forms  along  the  course  of  the  ureter  and  is  accompanied  by  diminished 
secretion  of  urine  and  hematuria. 

Injuries  0}  the  bladder  may  be  intraperitoneal  or  extraperitoneal. 
In  extraperitoneal  tears  there  are  evidences  of  dullness  above  the 
pubis,  the  area  of  dullness  not  changing  with  change  of  the  position  of 
the  patient;  or  there  is  bulging  toward  the  rectum  at  the  base  of  the 
bladder,  to  be  felt  per  rectum. 

Intraperitoneal  ruptures   of  the  bladder  cannot   be  differentiated 


Fig  .  160. — Method  of  Examination  to  Determine  Abnormal  Mobu.ity  or  Enlargements  of  the  Kidney. 
This  method  is  also  used  in  the  determination  of  the  presence  or  absence  of  an  enlargement  of  the  kidney. 
The  right  hand  of  the  examiner,  when  examining  the  right  kidney,  is  placed  behind  the  patient  in  a  space  be- 
tween the  last-rib  and  the  crest  of  the  ilium,  so  that  the  parts  lying  behind  the  kidney  can  be  raised  up  to  meet  the 
opposite  hand,  which  is  pressed  down  upon  it.  When  examining  for  a  floating  kidney  the  lower  pole  of  the 
kidney  can  be  felt  to  slip  across  the  hand  lying  on  the  anterior  surface  of  the  abdomen. 


as  such  except  when  symptoms  of  peritonitis  appear.  A  diagnosis 
at  this  time,  as  was  stated  before,  is  of  comparatively  little  value  from 
an  operative  standpoint.  In  both  extraperitoneal  and  intraperitoneal 
ruptures  of  the  bladder  the  catheter  can  be  easily  passed  into  the  bladder. 
The  urine  is  slightly  blood-tinged,  much  less  than  in  injuries  of  the  kid- 
ney, and  the  quantity  of  urine  obtained  is  very  small  or  there  may  be 
none  at  all. 

The  injection  test  for  perforation  or  rupture  of  the  bladder  is  but 
Httle  to  be  relied  upon.     This  test  consists  in  inserting  into  the  bladder 


244  THE   ABDOMEN. 

a  definite  quantity,  usually  from  four  to  six  ounces,  of  sterile  water. 
If  the  bladder  is  perforated,  the  greater  portion  or  all  of  this  leaks  out 
into  the  peritoneal  cavity  or  into  the  extraperitoneal  tissue,  and  a 
smaller  quantity  than  was  put  in  returns  through  the  catheter.  This 
test  is  unreliable  because  the  tear  or  perforation  may  be  valve-like 
in  character,  allowing  but  a  small  quantity  to  escape,  or  the  urethra 
may  be  torn  at  the  neck  of  the  bladder. 

The  most  reliable  signs  of  injury  of  the  bladder  at  an  early  stage 
are  (a)  the  history  of  and  the  location  of  the  injury;  (&)  the  presence 
of  practically  no  urine  in  the  bladder  when  catheterized,  and  this 
bloody  and  in  small  quantity;  (c)  the  pain  over  the  bladder;  (d)  the  con- 
stant desire  but  inability  to  urinate. 

When  peritonitis  has  set  in,  it  is  impossible  to  state  in  any  case 
whether  this  has  been  due  to  perforation  of  the  bladder  or  of  some 
portion  of  the  alimentary  canal.  Fractures  of  the  pelvis  are  often 
accompanied  by  injuries  of  the  bladder  and  urethra  (see  page  490). 

Cases  in  which  Symptoms  of  Internal  Hemorrhage  Predominate.- — 
These  will  be  found  more  or  less  characteristic  of  ruptures  of  the  liver 
or  spleen  or  of  the  intraperitoneal  ruptures  of  the  kidney.  Pain, 
localized  tenderness,  and  rigidity  situated  over  the  splenic  region, 
accompanied  by  evidences  of  hemorrhage  into  the  peritoneal  cavity,  are 
indicative  of  injury  of  the  spleen.  The  same  symptoms  located  over 
the  region  of  the  liver,  especially  if  the  pains  radiate  to  the  shoulders, 
are  typical  of  injuries  of  the  liver. 

In  injuries  of  the  liver  and  spleen,  and  in  those  of  the  kidney  in  which 
the  blood  escapes  into  the  general  peritoneal  cavity,  the  diagnosis  may 
be  made  from  these  local  signs,  such  as  tenderness,  rigidity,  etc.,  added 
to  the  presence  of  evidences  of  a  shifting  line  of  dullness  in  the  flanks, 
i.  e.,  of  free  fluid  in  the  peritoneal  cavity.  Icterus,  when  present,  is 
of  great  value  as  indicating  an  injury  of  the  liver.  The  presence  of 
free  blood  in  the  peritoneal  cavity,  whether  due  to  an  injury  of  the 
omentum  or  of  the  mesentery,  of  the  deep  epigastric  artery,  or  of  the 
liver,  spleen,  or  kidney,  causes  early  symptoms  of  so-called  peritonism  or 
peritoneal  irritation.  These  are  similar  to  those  of  a  beginning  peri- 
tonitis, but  are  less  rapid  in  their  onset.  They  consist  of  gradually 
increasing  pulse-rate,  tympanites,  and  leukocytosis.  These,  however, 
gradually  subside  if  the  blood  remains  aseptic  and  is  absorbed. 

Injuries  of  the  pancreas  cause  shock,  vomiting,  and  localized  pain 
over  the  epigastrium,  and  often  distention  of  the  upper  abdomen. 
Fractures  of  the  ribs  accompany  the  subcutaneous  injuries  of  the  liver 
and  spleen  in  many  cases. 


ACUTE    ABDOMINAL    AFFECTIONS. 


245 


Acute  Abdominal  Affections. 

When  called  to  the  bedside  of  a  patient  suffering  from  an  acute 
abdominal  condition,  every  effort  should  be  made  to  make  a  diagnosis 
at  as  early  a  period  as  possible. 

This  diagnosis  should  not  only  include  the  viscus  involved,  but  the 
character  of  the  pathologic  process. 

In  the  examination  of  such  a  case  it  is  well  to  have  a  more  or  less 
routine  method  of  examination,  in  order  that  no  organ  may  be  over- 
looked. 

There  is  no  one  group  of  symptoms  common  to  all  acute  abdominal 


Fig.  161. — Locations  of  Various  Foci  of  Suppuration  in  Abdominal  Cavity. 
SPA,  Subphrenic  abscess  pushing  hver  away  from  abdominal  wall;   RLA,  abscess  of  right  lobe  of  liver 
LLA,  abscess  of  left  lobe  of  liver;   PS,  peri-pancreatic  suppuration;   A'',  location  of  abscesses  within  kidney 
(pyelonephritis);  PN,  location  of  perinephritic  suppuration;    P,  peritoneal  cavity;    Si,  lumen  of  stomach; 
5,  abscess  of  spleen;  R,  retroperitoneal  tissue. 


conditions.  On  the  other  hand,  symptoms  so  group  themselves  that 
it  will  be  found  of  aid  to  divide  the  cases  into  four  classes.  The  lines 
between  these  are  not  sharply  drawn  because  occasionally  cases  appar- 
ently belonging  to  one  group  will  be  found  to  belong  more  properly 
to  one  of  the  others.  For  practical  purposes,  however,  such  a  class- 
ification will  be  found  useful  clinically,  and  is  as  follows : 

1.  Those  in  which  inflammatory  symptoms  appear  early  and 
predominate. 

2.  Those  in  which  pain  of  varying  intensity  is  the  prominent  s}Tnp- 
tom.  It  may  be  followed  by  signs  of  localized  or  diffuse  peritonitis 
or  by  the  symptoms  of  intestinal  obstruction. 


246 


THE   ABDOMEN. 


3.  Those  cases  in  which  the  symptoms  of  intestinal  obstruction 
are  the  most  prominent  from  the  onset. 

4.  Those  in  which  either  shock  or  hemorrhage  or  both  are  marked, 
and  are  followed  by  signs  of  peritonism  (signs  of  bowel  paralysis  of 
milder  degree  than  in  obstruction). 

The  various  acute  conditions  which  can  thus  be  classified  are: 


GROUP  I. 

GROUP  II. 

GROUP  III. 

GROUP  IV. 

Pain  a  Prominent  Early  Symp- 

Early   Signs    of 

Early  Signs  of 

Early  Symptoms  of  Suppura- 
tion. 

tom     FOLLOWED    OR    NOT    BY 

Signs  of  Peritonitis  or  In- 
testinal Obstruction. 

Intestinal 
Obstruction. 

Internal 
Hemorrhage. 

I.  Acute  cholecystitis. 

I.  Appendicitis. 

All  forms  of  in- 

I. Extrauter- 

testinal    ob- 

ine  hem- 

2. Hepatic  infections. 

2.  Gallstones    or    biliary 

struction. 

orrhage. 

(a)   Single  or  tropical  ab- 

colic. 

(a)    Strangula- 

scess. 

tion  by  bands, 

2.  Rupture 

(b)   Suppurative       pyle- 

3. Perforation  of    hollow 

by  adhesions 

of  aneur- 

phlebitis. 

viscera. 

through  aper- 

ysms. 

(c)    Catarrhal   and   sup- 

(a)  Gastric  ulcer. 

tures,    or    by 

purative  cholangitis. 

(b)   Duodenal  ulcer. 

Meckel's    di- 

(c)  Typhoid  ulcer. 

verticulum. 

3.  Primary  forms  of  peri- 

(b)  Volvulus. 

tonitis. 

4.  Acute  pancreatitis. 

(c)    Intussus- 

(a) Acute  tubercular. 

ception. 

(b)   Pneumococcus. 

5.  Renal  colic. 

■     (d)  By  tumors 

(c)    Gonorrheal. 

or    foreign 

6.  Kinking   of   ureter  in 

bodies. 

4.  Renal  infections. 

floating  kidney  (Dietl's 

(e)     Adynamic 

(a)  Pyonephrosis. 

crises). 

ileus. 

(6)   Pyelonephritis. 

(c)    Perinephritis. 

7.  Embolism  or  thrombo- 

(d) Metastatic  abscess. 

sis   of  the  mesenteric 
vessels. 

5.  Subphrenic  abscess. 

8.  Torsion  of  pedicles  of 

6.  Suppurating   echinococ- 

ovarian  or  uterine  tu- 

cus cysts  of  the  liver. 

mors. 

7.  Pericolitis  sinistra. 

8.  Multinle     abscesses    of 

9.  Torsion   of   spermatic 
cord. 

omentum. 


ID.  Visceral  crises  in  tabes  or  in  erythema  group. 

11.  Angina  sclerotica  abdominis. 

12.  Referred  pain  from  thoracic  or  spinal  affections. 

13.  Inflammation  of  intraabdominal  portion  of  vas  deferens. 


Group  I. — Early  Symptoms  of  Suppuration. 

I.  ACUTE  CHOLECYSTITIS. 

In  acute  cholecystitis,  occurring  without  gallstones,  there  is  pain 

referred  to  the  gallbladder  region,  tenderness  and  muscular  rigidity  over 

the  same  area,  fever,  leukocytosis,  and  an  increased  pulse-rate.     In 


ACUTE    CHOLECYSTITIS. 


247 


addition,  an  area  of  dullness  can  be  outlined  by  percussion  and  a  tumor 
felt  at  times  by  palpation  just  below  the  right  costal  arch. 

If  the  liver  is  located  at  a  lower  level  in  the  abdominal  cavity,  as  the 
result  of  a  hepatoptosis,  or  if  there  is  a  long  Riedel's  lobe  which  has 
carried  the  gallbladder  with  it  (Fig.  162),  all  of  the  above  signs  are  found 
at  the  level  of  the  umbiHcus  or  even  below  it.  If  pus  has  formed  in 
the  gallbladder  (empyema)  the  fever  is  higher  and  continuous  in  type, 
and  the  leukocytosis  quite  marked.  In  cholecystitis  complicating 
typhoid  the  symptoms 
are  often  overshad- 
owed by  those  of  the 
typhoid  itself.  Such 
cases  show  a  distinct 
Widal  reaction. 

Differential 
Diagnosis.  —  i.  Ap- 
pendicitis . — In  ap- 
pendicitis the  tender- 
ness and  rigidity  are 
lower  down,  fever  and 
leukocytosis  are  not  so 
marked  at  an  early 
stage,  and  there  is 
more  apt  to  be  severe 
colicky  pain. 

If,  however,  the 
gallbladder  is  located 
lower  than  normal  the 
differentiation  be- 
tween a  cholecystitis 
and  an  appendicitis 
may  be  very  difficult. 

2.  Biliary  Colic. — ^In  gallstone  colic  the  same  local  signs  appear 
as  in  cholecystitis,  but  there  is  less  fever,  less  leukocytosis,  and  less 
constitutional  disturbance,  and  the  pains  are  far  more  severe  and 
radiate  to  the  right  shoulder,  less  often  than  to  the  left. 

Phlegmonous  Cholecystitis. — This  grave  form  of  cholecystitis 
can  be  recognized  by  the  greater  severity  of  the  initial  symptoms.  The 
pain  in  the  right  hypochondrium  is  more  severe  and  sudden  in  its 
onset  than  in  gallstone  colic,  and  there  is  far  more  general  disturbance. 
These  latter  septic  symptoms  are  rapid,  feeble  pulse,  cold  sweats,  sub- 


FiG.  162. — Riedel's  Lobe  of  Liver  and  Area  of  Dullness  or 

Tumor  Due  to  Cystic  Enlargement  of  the  Gallbladder. 

RL,  Right  lobe  of  liver  ;  LL,  left  lobe  of  liver  ;  R,  Riedel's  lobe  ;  CG, 

cysticaUy  dilated  gallbladder. 


THE    ABDOMEX, 


normal   temperature,    collapse,    faintness,    great   prostration,    and   the 
early  appearance  of  the  signs  of  a  general  peritonitis. 


2.  HEPATIC  INFECTIONS. 

SINGLE  OR  TROPICAL  ABSCESS. 

The  occurrence  of  irregular  fever  accompanied  by  chills,  sweats, 
and  pain  over  the  Hver  and  enlargement  of  that  organ,  in  a  patient 

who  has  previously 
suffered  from  dysen- 
tery, should  lead  one 
to  suspect  an  abscess 
of  the  hver.  A  bulg- 
ing below  the  right 
costal  arch  will  con- 
firm such  a  diagnosis. 
The  pain  in  ab- 
scesses of  the  right 
lobe  is  referred  to  the 
right  shoulder,  and  in 
those  of  the  left  side, 
to  the  corresponding 
scapular  region. 

The  fever  may  be 
quite  regularly  inter- 
mittent, like  a  malar- 
ial, but  is  usually  quite 
irregular. 

The  liver  is  en- 
larged in  all  directions 
and  is  tender  to  the 
touch.  The  tender- 
ness may  at  times  be 
quite  localized  over  the  abscess.  Exploratory  puncture  is  of  great  value 
in  confirming  the  presence  of  pus.  A  negative  result  does  not  exclude  an 
abscess,  as  the  needle  may  become  occluded  or  pass  through  the  abscess. 
Differential  Diagnosis.— i.  Empyema. — The  Hver  is  not  enlarged 
in  a  do^^Tlward  direction.  There  are  marked  signs  of  compression  of 
the  lung  if  the  empyema  is  a  diffuse  one  and  the  upper  border  of  dull- 
ness is  either  concave  upward  or  horizontal,  while  in  hepatic  abscess 
it  is  convex  (Fig.  163)  and  the  septic  symptoms  are  more  marked.     If 


Fig.  163. — Areas  of  Dullness  Frequently  Observed  m  Right- 
sided  Subphrenic  Abscesses,  and  in  Abscesses  of  the  Right 
Lobe  of  the  Li\'er. 

RL,  Right  lobe  of  liver;  LL,  left  lobe  of  liver;  LA ,  abscess  of  lateral 
subphrenic  space;  DA,  abscess  of  dome  of  diaphragm. 


HEPATIC    INFECTIONS.  249 

an  empyema  and  hepatic  abscess  coexist  a  differentiation  is  impossible. 
The  same  is  true  for  an  encapsulated  diaphragmatic  empyema. 

2.  Malaria. — The  absence  of  leukocytosis  and  the  finding  of  Plas- 
modia serve  to  distinguish  this  disease.  It  must  not  be  forgotten  that 
in  some  cases  of  malaria  the  organisms  are  not  found  until  after  quinin 
has  been  administered. 

3.  Suppurative  Pylephlebitis  or  Cholangitis. 

4.  Subphrenic  Abscess. — (See  page  253.) 

SUPPURATIVE  PYLEPHLEBITIS. 

This  most  frequently  follows  appendicitis,  toward  the  end  of  the 
attack.  It  results  in  the  formation  of  multiple  abscesses  in  both  lobes 
of  the  liver  (Fig.  164).  It  may  often  follow  what  were  interpreted 
clinically  to  have  been  mild  cases  of  appendicitis. 


Fig.  164. — Multiple  Abscesses  OF  Liver. 
Due  to  a  septic  pylephlebitis  secondary  to  appendicitis. 

If  a  septic  or  pyemic  condition  follows  appendicitis  either  a  pyle- 
phlebitis or  a  subphrenic  abscess  must  be  thought  of.  In  pylephlebitis 
there  are  chills,  irregular  fever,  sweats,  jaundice,  and  a  uniformly 
enlarged  and  very  tender  liver.  The  patients  appear  to  be  very  septic 
and  soon  succumb  to  the  pyemia. 

Differential  Diagnosis. — i.  From  Tropical  Abscess. — The  clinical 
picture  is  not  that  of  such  a  severe  sepsis  as  in  pylephlebitis,  the  liver 
is  not  so  uniformly  tender,  and  there  may  be  bulging  at  the  costal  arch. 

2.  Suppurative  or  Catarrhal  Cholangitis  Complicating  Gallstones 
in  the  Common  Duct. — There  is  continuous  or  intermittent  jaundice, 
a'history  of  colics,  and  the  septic  intoxication  is  never  as  marked  as 


250  THE    ABDOMEN, 

in  pylephlebitis.  If  multiple  foci  of  suppuration  occur  in  a  cholangitis, 
it  can  only  be  differentiated  from  a  pylephlebitis  by  the  history  of  an 
appendicitis  in  the  latter. 

3.  Typhoid  Fever. — The  fever  is  almost  always  continuous,  the 
pulse  is  slower,  chills  and  sweats  are  rare,  and  there  is  leukopenia.  A 
positive  Widal  reaction  and  the  typhoid  bacilli  obtained  from  a  blood 
culture  are  characteristic  of  typhoid. 

4.  Malaria. — The  finding  of  plasmodia,  the  presence  of  leukopenia, 
and  the  more  regular  type  of  intermittent  temperature,  as  well  as  the 
lack  of  local  hepatic  symptoms,  speak  for  malaria. 

3.  PRIMARY  FORMS  OF  PERITONITIS. 

Acute  Tubercular  Peritonitis. — This  may  begin  in  an  acute 
manner  with  fever  to  103°  to  104°,  abdominal  tenderness,  and  the 
symptoms  of  ordinary  acute  peritonitis,  such  as  tympanites,  etc.  In 
these  cases  the  absence  of  a  cause  for  the  peritonitis  and  the  examina- 
tion of  the  lungs  and  other  parts  of  the  body  for  evidence  of  tubercu- 
losis will  be  of  aid  in  making  a  diagnosis. 

Acute  Gonorrheal  Peritonitis. — This  is  usually  well  localized 
in  the  pelvis,  but  may  become  general.  In  the  former  case  the  inflam- 
matory signs,  such  as  severe  pain,  tenderness,  muscular  rigidity,  and 
tympanites,  are  local.  In  the  general  form  there  is  a  very  acute  onset, 
in  which  abdominal  distention,  tenderness,  and  rigidity  are  quite 
diffuse  and  are  accompanied  by  elevation  of  temperature  and  a  rapid 
pulse.  The  diagnosis  may  be  made  from  the  previous  history  of 
leukorrhea  or  of  post-marital  infection,  or  of  a  preceding  py ©salpinx 
followed  by  the  acute  local  or  general  peritonitic  symptoms.  The 
fact  that  the  condition  spontaneously  improves  in  a  few  days,  instead 
of  being  progressive  as  in  ordinary  diffuse  forms  of  peritonitis,  is  also 
very  important. 

Pneumococcus  Peritonitis. — This  occurs  almost  exclusively  in 
young  children  of  both  sexes.  It  may  accompany  or  follow  thoracic 
conditions,  such  as  pericarditis  or  empyema,  or  occur  independently. 

The  diagnosis  may  be  made  from  the  age  and  the  sudden  onset  of 
peritonitic  symptoms,  such  as  fever,  abdominal  distention,  vomiting,  and 
tenderness,  followed  in  a  few  days  by  diarrhea  and  later  by  the  for- 
mation of  a  tense  cystic  mass  in  the  hypogastrium  accompanied  by 
fever  and  signs  of  exhaustion. 


RENAL    INFECTION.  25 1 

4.  RENAL  INFECTION. 

Renal  suppuration  is  usually  chronic  in  its  course,  but  it  may  appear 
in  such  an  acute  form  as  to  necessitate  its  consideration  here. 

The  principal  varieties  of  acute  renal  disease  of  the  suppurative 
type  are: 

1.  Pyelonephritis. 

2.  Perinephritis. 

3.  Metastatic  abscesses. 

4.  Pyonephrosis. 

PYELONEPHRITIS. 

This  may  follow  suppuration  in  the  lower  urinary  tract,  such  as  the 
bladder  or  urethra,  or  it  may  be  hematogenous  in  origin,  i.  e.,  conveyed 
through  the  blood  from  distant  foci  of  suppuration.  In  some  cases  it 
manifests  itself  by  a  rigor  or  succession  of  chills,  followed  by  fever 
and  sweats.  There  is  scarcely  any  tenderness  or  pain  over  the  kidney 
in  some  cases;  in  others  there  are  typical  colicky  pains  following 
along  the  ureter  to  the  bladder  and  radiating  to  the  testis  and  thighs. 

The  diagnosis  in  the  first  class  of  cases,  where  there  are  no  local 
renal  signs  and  the  urine  is  negative,  is  very  difficult  and  can  only  be 
made  from  the  existence  of  a  cystitis  or  other  cause  of  infection,  and 
the  absence  of  signs  of  a  pyemia  or  of  a  mahgnant  endocarditis.  In 
the  more  locahzed  form  the  enlarged  tender  kidney  and  the  ureteral 
pains,  associated  with  purulent  acid  urine,  are  characteristic.  In 
some  of  these  cases  the  chills  and  irregular  fever  are  followed  by  a 
more  coQtinuous  type  of  fever,  resembling  typhoid,  with  stupor  and 
delirium,  a  condition  known  as  urosepsis. 

Differential  Diagnosis.— P)'^;?^/^. — In  this  septic  condition  there 
are  signs  of  secondary  foci  in  the  lungs,  spleen,  and  joints,  which  are 
absent  in  suppurative  pyelonephritis,  and  in  pyemia  a  primary  focus 
is  usually  to  be  found. 

Septicemia. — In  the  acute  forms  septicemia  runs  a  more  rapid 
course,  the  pulse  and  respirations  are  higher,  and  there  is  greater 
prostration. 

PERINEPHRITIS. 

In  this  affection  there  is  pain  in  the  lumbar  region,  at  times  radiat- 
ing into  the  thigh  or  testes.  The  pain  is  usually  quite  severe,  and 
the  corresponding  renal  region  is  very  tender,  rigid,  and  often  edema- 
tous. These  local  signs  are  accompanied  by  evidences  of  deep-seated 
suppuration,   such  as   chills,   fever,   furred   tongue,   vomiting,   stupor. 


252  THE    ABDOMEN. 

and  even  delirium.  There  is  often  a  peculiar  lameness;  the  patient 
walks  with  the  body  bent  forward  and  inclined  to  the  affected  side, 
the  thigh  being  held  flexed. 

The  urine  may  be  normal  if  the  disease  be  of  extraneous  origin,  or 
it  may  contain  blood  if  it  follow  an  injury,  or,  finally,  in  a  few  cases  there 
is  pus  in  the  acid  urine. 

Differential  Diagnosis. — i.  Lumbago  is  but  rarely  accompanied 
by  fever  or  leukocytosis.  The  pain  is  most  often  bilateral  and  does 
not  radiate  to  the  testis  or  thigh, 

2.  Spondylitis. — The  pain  extends  around  the  body;  it  is  relieved 
by  suspending  the  patient.  The  tenderness  is  over  the  spine  itself, 
which  is  held  in  a  rigid  manner,  best  seen  when  the  patient  is  asked  to 
bend  forward.  There  is  also  but  little  fever  or  leukocytosis  and  the 
symptoms  are  more  gradual  in  their  onset. 

3.  Hip-joint  Disease. — The  pain  and  tenderness  are  lower  down, 
often  referred  to  the  knee.  There  is  limitation  of  motion  at  the  hip, 
and  when  the  limb  is  straightened  there  is  marked  lordosis  of  the  lum- 
bar spine.     The  x-xdij  often  shows  a  pathologic  head  of  the  femur. 

4.  Appendicitis. — In  those  cases  in  which  the  appendix  is  directed 
down  or  inward  (Fig.  168)  the  pain  is  in  the  right  iHac  fossa  and  followed 
by  nausea  and  vomiting.  In  perinephritis  the  pain  and  swelling  are 
higher  up  in  the  iliocostal  space.  In  inflammation  in  an  appendix 
which  lies  behind  the  cecum  and  ascending  colon  with  its  tip  directed 
upward,  the  rigidity  of  the  abdominal  wall,  tenderness,  and  pain  may 
greatly  resemble  those  of  a  right-sided  perinephritis.  In  appendi- 
citis, however,  the  pain  is  usually  followed  by  nausea  and  vomiting. 
The  rigidity  and  swelling,  etc.,  of  a  perinephritis  usually  extend  fur- 
ther back  in  the  iliocostal  space. 

METASTATIC  SUPPURATION  OF  THE  KIDNEY. 

If  this  occurs  as  a  manifestation  of  pyemia  it  cannot  be  recognized 
except  from  the  locahzed  pain  and  the  sudden  pyuria.  If,  however, 
as  not  rarely  occurs,  abscesses  form  in  one  or  both  kidneys,  as  the 
result  of  a  purulent  focus  elsewhere  which  has  not  caused  pyemia,  the 
severe  pain  over  the  affected  kidney,  the  occurrence  of  repeated  chills 
and  fever,  and  the  tenderness  and  enlargement  of  the  affected  kidney 
will  permit  a  diagnosis  to  be  made. 

PYONEPHROSIS. 

This  affection  is  not  apt  to  run  an  acute  course.  The  enlarged 
kidney  can  usually  be  distinctly  felt  as  greatly  enlarged,  there  is  no 
rigidity  of  the  abdominal  muscles,  no  edema  of  the  skin,  and  there  is 


i3    tit  <J 


o    f^ 


O    CfQ     ?T-    m     O 

o         :s"  Ti    o 
g    3   ^    Ei    S 


;i  5.  OP  ° 

r^-   m'   ■-:■   li 


H-  -•  c   ir  :i 


13    "T^ 


^    - 


&•  e 


a"  P 


a     I— '  n 


p^  „ 


o-  a" 


5   S-  0    2 


2.  ^.  3   s. 


re     D     C^    5^     Ij 


<S    3 


«>  S    t=  P 


D.  5 


^tJ 


'^    B  o.     H 


^  a  g^  "^    55 
3   £2-  -^   5'    ■ 


P    'T3      _ 

cr  5"  5" 


n>  '<;     n   oj 


rt  (i  5.  n 
£^  ">  2 
2    P    ^    ^ 


,—   rD     «■ 


2    o 


w    re 


SUBPHRENIC   ABSCESS. 


253 


a  history  of  long  duration  of  the  symptoms.  In  some  cases  there  is 
a  previous  history  of  an  obstinate  lumbago  which  was  never  properly 
diagnosed  as  of  renal  origin.  In  other  cases  there  is  a  history  of 
attacks  of  renal  colic. 


5.  SUBPHRENIC  ABSCESS. 

(See  Figs.  163  and  165.) 

This  condition  most  frequently  follows  appendicitis  if  situated  in 
the  right  subphrenic  space,  and  perforations  of  the  stomach  or  duo- 
denum if  located  in  the  left  subphrenic  space.  It  may,  however, 
occasionally  occur  in  the  latter  locality  after  an  acute  appendicitis 
or  a  diffuse  septic  peri- 
tonitis. The  attack  of 
appendicitis  need  not 
have  been  complicated 
by  pus  formation  and 
the  subphrenic  abscess 
may  follow  days  to 
months  after  the  at- 
tack. 

The  history  of  a 
sudden  recurrence  of 
fever  and  of  other 
signs  of  suppuration, 
such  as  leukocytosis, 
etc.,  toward  the  end  of 
or  shortly  after  an  at- 
tack of  appendicitis 
associated  with  pain  in 
the  right  or  left  hepatic 
region,  should  lead  to 
a  search  for  a  sub- 
phrenic abscess.  In 
the  case  of  the  left- 
sided  abscesses  following  gastric  or  duodenal  ulcer  there  is  a  previous 
history  of  pain  in  the  epigastrium  and  of  vomiting  of  blood,  or  of  copious 
tarry  stools  followed  by  the  symptoms  of  infection. 

The  diagnosis  must  be  based  on  the  physical  signs  and  the  general 
evidence  of  deep-seated  infection,  such  as  fever,  rapid  pulse,  leukocy- 
tosis, etc. 


Fig.  166. — Area  OF  Dullness  in  I.eft-sided  Subphrenic  Abscess. 

The  dark  area  shows  absolute  dullness,  the  area  indicated  by  vertical 

lines  corresponds  to  the  zone  of  tympany  (A.  Martin). 


254  THE    ABDOMEN. 

In  right-sided  subphrenic  abscesses  the  liver  is  usually  pushed  down- 
ward. Over  the  abscess  there  is  a  continuation  upward  of  liver  dullness 
for  a  variable  distance  with  a  corresponding  suppression  of  pulmonary- 
sounds.  A  subphrenic  abscess  may  cause  a  horizontal  line  of  dullness 
or  one  that  is  convex  upward.  The  area  of  dullness  may  be  more  marked 
at  some  one  point,  thus  resembling  an  encapsulated  empyema.  If 
gas  is  present  in  the  abscess,  dullness  is  replaced  by  tympany  and 
there  are  succussion  sounds,  as  in  pyopneumothorax. 

The  pain  may  be  strictly  localized  over  the  right  or  left  hypochon- 
driac regions  or  may  be  diffuse,  and  not  infrequently  there  is  tenderness 
and  rigidity,  rarely  edema  of  the  overlying  tissues. 

Differential  Diagnosis. — Empyema.- — This  is  at  times  very  diffi- 
cult. Rapid  respiration,  cough,  expectoration,  and  the  history  of  a 
preceding  pneumonia  speak  for  empyema.  The  line  of  dullness  in 
the  diffuse  form  is  said  to  be  concave  upward,  but  this  may  occur  in 
subphrenic  abscess  as  well.  Between  an  encapsulated  empyema 
close  to  the  diaphragm  and  a  subphrenic  abscess,  differentiation  is 
impossible.  The  physical  signs  for  both  empyema  and  subphrenic 
abscess  are  so  nearly  alike  that  greater  reliance  should  be  placed  on 
the  etiology  and  character  of  the  pus  obtained  by  exploratory  aspiration. 
The  latter  is  apt  to  have  the  peculiar  acid  fetor  of  colon  bacillus  pus, 
while  in  empyema  there  is  seldom  any  odor.  Again,  in  subphrenic 
abscess  the  explorator}^  puncture  reveals  the  presence  of  pus  at  a  lower 
level  than  in  empyema. 

Abscess  of  the  Liver. — Here  the  history  of  a  preceding  attack  of 
dysentery  and  the  less  marked  extension  of  the  liver  dullness  upward 
are  of  value.  In  multiple  abscesses  of  the  liver  following  appendicitis 
there  is  greater  evidence  of  sepsis  and  more  general  enlargement 
and  tenderness  of  the  liver. 


6.  SUPPURATING  ECHINOCOCCUS  CYSTS  OF  THE  LIVER. 
These  may  present  the  same  symptoms  and  local  findings  as  single 
or  tropical  abscesses.  There  is,  however,  no  history  of  dysentery,  and 
the  occupation  of  the  patient  frequently  is  suggestive  in  that  the  disease 
is  much  more  common  in  those- brought  in  close  contact  with  sheep  and 
sheep-dogs.  In  the  absence  of  a  distinct  tumor  and  the  history  or 
evidence  of  the  presence  of  similar  cysts  elsewhere,  a  recognition  of  this 
condition  is  impossible.  When  the  tumor  is  distinct,  as  is  often  the 
case,  aspiration  will  frequently  show  booklets. 


MULTIPLE    ABSCESSES    OF    THE    OMENTUM. 


255 


7.  PERICOLITIS  SINISTRA. 

This  is  a  condition  of  acute  infection  due  either  to  perforation  of 
the  appendices  epiploicae  or  of  the  haustra  or  saccuH  of  the  descending 
colon  and  sigmoid  flexure.  There  is  sharp  pain  in  the  left  iliac  region, 
with  rise  of  temper- 
ature and  vomiting, 
the  same  sequence  of 
symptoms  so  frequent- 
ly seen  in  appendicitis. 
On  palpation  there  is 
deep  tenderness,  rigid- 
ity of  the  abdominal 
wall,  and  the  forma- 
tion gradually  of  a 
tumor  in  the  left  iliac 
fossa  accompanied  by 
fever  and  leukocytosis. 

If  no  localized  in- 
traperitoneal abscess 
forms,  the  pus,  as  in 
one  case  observed  by 
the  author,  can  escape 
into  the  general  peri- 
toneal cavity  and  cause 

a  diffuse  peritonitis.  ^'''-  ^^V.-Most  frequent  D^ec.ion  oe  radiation  oe  Pain  in 

'^  Various  Acute  Abdominal  Afeections. 

L  and  G,  Gallbladder  and  hepatic  affections;  GU,  and  DU,  and 
F,  location  of  pain  in  gastric  and  duodenal  ulcers  and  pancreatic 
affections;  D,  occasional  radiation  of  pain  in  duodenal  ulcers  to  right 
iliac  region;  C,  location  of  pain  in  ordinary  intestinal  colics,  and  in 
early  stages  of  acute  appendicitis;  App,  various  radiations  of  pain 
in  appendiceal  inflammation;  R,  radiation  of  pain  in  ureteral  and 
renal  conditions,  along  the  line  of  the  ureter  toward  the  bladder, 
testes,  and  thighs;  S,  location  of  pain  in  sigmoiditis,  and  affections 
of  the  descending  colon.  The  arrow  pointing  downward  and  in- 
ward from  the  left  nipple  is  to  indicate  the  frequent  reference  of  pain 
in  thoracic  affections,  to  the  abdomen. 


MULTIPLE  AB- 
SCESSES OF  THE 
OMENTUM. 


Tliis  condition  may 
follow  abdominal  op- 
erations, especially 

those  for  radical  cure  of  hernia.     The  clinical  histor\^,  as  observed  in 
one  such  case  by  the  author,  was  the  following : 

Severe  pain  in  that  side  of  the  abdomen  upon  w^hich  the  wound 
was  situated,  with  rigidity  and  tenderness.  The  temperature  varied 
between  101°  and  104°  F.,  there  was  considerable  abdominal  distention, 
some  vomiting,  and  constipation. 

A  distinct  tumor  could  be  felt  extending  from  Poupart's  ligament 


256 


THE    ABDOMEN. 


toward    the    umbilicus.     The    greatly    thickened    omentum    in    these 
cases  contains  a  number  of  small  abscesses. 

The  diagnosis  depends  upon  the  signs  of  localized  peritonitis  with 
formation  of  tumor,  following  an  operation. 

Group  II. — Pain  a  Prominent  Early  Symptom, 
In  this  group  all  of  those  acute  conditions  are  included  in  which  the 
chief  symptom  is  pain.  This  is  accompanied  by  other  signs  of  involve- 
ment of  the  abdominal 
viscera.  In  many  of 
the  conditions  the  pain 
can  be  localized  fairly 
well  from  the  onset ;  in 
others,  such  as  appen- 
dicitis, it  is  often  dif- 
fuse at  first,  becoming 
more  definite  in  the 
course  of  a  few  hours. 


I.  APPENDICITIS. 
Diagnosis. — In 

every  case  of  appendi- 
citis the  diagnosis  may 
be  made  from  an  al- 
most constant  triad  of 
symptoms : 

1.  Pain  of  a  sud- 
den, severe,  often  col- 
icky nature. 

2.  Nausea  and 
vomiting. 

3.  Localized  ten- 
derness and  muscular 
rigidity. 

I.  Pain. — This  is  often  general  at  first,  but  soon  becomes  locaHzed, 
in  the  majority  of  cases,  in  the  right  ihac  region.  The  only  exceptions 
to  this  rule  are: 

{a)  When  the  appendix  is  directed  upward  toward  the  hver,  and 
especially  when  it  Hes  behind  the  ascending  colon  (Fig.  168),  the  pain 
may  be  referred  to  the  lumbar  or  right  hypochondriac  regions. 


Fig.  168. — XoRiiAL  Positions  of  Vermiform  Appendix. 
I,  Pointing  downward  and  inward  toward  the  pelvis;  2,  point- 
ing inward  and  to  the  left;  3,  pointing  upward  toward  the  liver,  and 
lying  either  in  front  or  behind  the  cecum.  G,  Normal  location  ot 
gallbladder;  Sp,  spleen;  L,  Uver;  the  letter  itself  is  placed  on  the 
left  lobe. 


APPENDICITIS. 


257 


(b)  When  the  appendix  points  inward  or  toward  the  pelvis,  the 
pain  is  referred  either  to  the  umbiHcus  or  to  the  left  iliac  region  (Fig.  168), 
and  is  often  accompanied  by  vesical  and  rectal  symptoms. 

2.  Vomiting. — This  accompanies  the  pain  as  a  primary  symptom 
or  follows  it  after  three  or  four  hours. 

If  the  nausea  and  vomiting  persist  or  reappear  at  a  later  period, 
they  are  danger-signals  of  a  beginning  peritonitis. 

3.  Tenderness  and  Muscular  Rigidity. — As  a  rule,  these  are  most 


Fig.  169. — Method  of  Examination  of  the  Appendix  Region,  with  the  Limbs  Flexed  upon  the 

Abdomen. 
The  limbs  should  be  raised  to  such  a  height  that  the  soles  of  the  feet  can  rest  easily  on  the  bed  or  table. 
The  patient's  back  should  be  somewhat  elevated,  and  he  or  she  should  be  instructed  to  relax  the  abdomi- 
nal muscles  by  diverting  his  attention  or  asking  them  to  open  the  mouth.  Pressure  is  then  made  along  the 
right  border  of  the  right  rectus,  with  the  entire  palmar  surface  of  all  of  the  fingers  of  the  right  hand,  and  not 
with  the  tips  of  these  fingers. 


marked  over  the  right  iliac  region  and  are  best  elicited  when  the  shoulders 
are  raised  and  the  thighs  flexed  (Fig.  i6g).  The  tenderness  is  quite 
superficial  and  manifests  itself  when  the  shghtest  pressure  is  made. 
Deep  tenderness  can  be  found  only  with  difficulty  during  the  acute 
stage,  owing  to  the  muscular  rigidity.  The  examination  should  never 
be  forcible.  A  good  plan  is  to  have  the  patient  palpate  the  abdomen 
gently  with  the  index-finger  and  ask  him  to  locate  the  most  tender  point. 
Often  the  most  marked  tenderness  can  be  obtained  by  rectal  or  vaginal 
17 


258 


THE    ABDOMEN. 


examination.  The  rectal  method  is  especially  of  value  in  children, 
where  the  appendix  so  often  points  toward  the  pelvis. 

The  muscular  rigidity,  being  due  to  a  reflex  contraction,  is  a  very 
valuable  sign  when  it  accompanies  pain,  vomiting,  and  tenderness. 
This  symptom  is  best  obtained  by  gradually  and  lightly  sliding  the 
hand  over  the  suspected  region. 

If  the  appendix  lies  in  either  of  the  unusual  positions  referred  to 
above,  the  tenderness  and  rigidity  are  correspondingly  altered  in  loca- 
tion (Fig.  167). 


Fig.  170. — Method  of  Palpating  the  Appendix  with  the  Limbs  Outstretched. 
The  fingers  are  laid  flat  upon  the  abdominal  wall,  the  examiner  standing  to  the  right  of  the  patient.  Either 
the  right  or  left  hand  may  be  used.  The  appendix  may  usually  be  felt  on  the  outer  edge  of  the  right  rectus  muscle, 
if  enlarged,  and  if  the  abdominal  walls  are  relaxed.  Palpation  should  be  carried  out  with  as  large  a  surface 
of  the  fingers  as  possible,  and  not  by  prodding  the  patient's  abdomen  with  the  finger-tips.  This  method  is 
inferior  to  that  shown  in  Fig.  169. 


Pulse. — In  the  majority  of  cases  there  will  be  an  increase  in  the 
pulse-rate  with  the  onset  of  pain.  The  rate  may  be  from  80  to  100  for 
a  number  of  hours.  //  it  shows  a  gradual  increase  in  frequency  after 
the  first  twelve  hours  it  is,  as  a  rule,  an  ominous  sign.  The  steady  rise 
of  the  pulse- rate  to  no,  later  to  120  or  higher,  especially  if  it  is  jerky  in 
character,  is  of  great  value  in  the  diagnosis  of  a  beginning  peritonitis, 
especially  if  nausea  continues,  or  vomiting  is  repeated  and  the  area  of 
rigidity  and  tenderness  increase  and  are  combined  with  abdominal 
distention.  In  children  the  pulse-rate  is  much  higher  than  in  adults 
and  a  rapid  pulse  is  not  always  to  be  relied  upon. 


APPENDICITIS. 


259 


Fortunately  for  the  purpose  of  diagnosis  a  slow  pulse  is  but  rarely 
met  with.  The  author  recalls  a  pulse  of  66  and  a  temperature  of  99.6° 
in  a  case  of  extensive  spreading  peritonitis  following  appendicitis. 
The  muscular  rigidity,  tenderness,  and  tympanites  were  so  characteristic 
that  a  diagnosis  could  be  made  from  these  symptoms  alone. 

Temperature. — A  rise  in  temperature  usually  occurs  within  two 
to  three  hours  after 
the  beginning  of  an 
attack.  In  the  milder 
catarrhal  cases  it  is  not 
higher  than  100°  or 
101°  F.,  but  even  this 
is  inconstant.  If  fever 
persists  and  increases 
gradually  during  the 
first  forty-eight  to 
seventy-two  hours,  it 
generally  means  an 
encapsulated  abscess. 
If  the  temperature 
drops  suddenly,  es- 
pecially if  accom- 
panied by  a  rise  of 
pulse-rate  and  in- 
crease of  rigidity,  it  is 
significant  of  gangrene 
or  a  beginning  peri- 
tonitis. Persistent 
temperature  or  fever 
occurring  after  ap- 
parent recovery,  signi- 
iies  some  complication 

like  pylephlebitis  or  subphrenic  abscess.     The  most  accurate  temper- 
atures are  those  taken  per  rect-um. 

Leukocytosis. — Catarrhal  appendicitis  is  accompanied  by  a  mild 
degree  of  leukocytosis,  rarely  above  12,000.  An  increasing  leukocy- 
tosis, from  15,000  upward,  generally  indicates  a  severe  infection.  If 
the  count  remains  stationary,  it  is  indicative  of  a  walhng  off. 

If  the  leukocyte  count  decreases  gradually  in  a  mild  attack,  it 
signifies  improvement.  If  it  decreases  suddenly  after  a  severe  attack, 
it   signifies   gangrene,   perforation   with  beginning   peritonitis,   or  the 


Fig.  171. — Most  Frequent  Locations  of  Intraabdominal  Ab- 
scesses Following  Appendicitis. 
For  subphrenic  abscesses,  see  Figs.  163  and  166.  i,  Around 
cecum  and  appendix,  close  to  brim  of  pelvis;  2,  pelvic  form;  3,  around 
ascending  colon  and  hepatic  flexure;  4,  retrocecal  and  colic  forms;  5, 
left-sided  forms.     5,  Anterior  superior  spine  of  ilium. 


26o  THE    ABDOMEN. 

bursting  of  an  abscess  into  the  general  peritoneal  cavity.  The  majority 
of  cases  in  which  perforation  or  gangrene  occurs  early,  and  causes 
peritonitis,  have  a  low  leukocyte  count,  owing  to  the  lack  of  resistance 
on  the  part  of  the  organism  and  the  overwhelming  of  the  system  by 
the  toxins. 

Tumor. — As  an  early  sign  this  is  of  little  value,  owing  to  the  fact 
that  the  muscular  rigidity  is  so  marked  in  many  cases  that  deep  pal- 
pation is  both  difficult  and  dangerous.  In  other  cases  the  contracted 
edge  of  the  rectus  is  apt  to  feel  like  an  inflammatory  mass.  Again 
there  are  cases  where  the  omentum  wraps  itself  around  the  appendix 
and  forms  a  palpable  tumor.  When  the  acute  symptoms  have  sub- 
sided, a  tumor  can  often  be  felt  through  the  less  rigid  muscles.  Rectal 
examination  should  never  be  omitted,  especially  in  children,  where 
the  pelvis  is  shallow  and  the  appendix  is  more  apt  to  be  located  in  it. 

Differential  Diagnosis. — Acute  Gastro-intestinal  Disturbances. — 
In  these,  as  in  appendicitis,  there  is  often  a  history  of  indiscretion  in 
diet,  followed  by  abdominal  pain  and  vomiting.  In  acute  gastroduo- 
denal  catarrh  the  pain  is  felt  over  the  epigastrium  and  is  never  as 
severe  or  colicky  as  in  appendicitis.  The  nausea  and  vomiting  are 
far  more  marked  early  symptoms,  and  may  be  almost  constant.  There 
is  no  true  muscular  rigidity  and  but  shght,  if  any,  tenderness.  In 
intestinal  colic  the  pain  may  be  as  severe  as  in  appendicitis,  but  is  usually 
referred  to  the  umbilicus  and  does  not  become  more  intense,  as  it  does 
in  appendicitis.  There  is  also  no  locaHzed  rigidity  or  tenderness  and 
the  attack  often  subsides  as  soon  as  an  enema  is  given,  while  in  appen- 
dicitis the  symptoms  become  more  marked  from  hour  to  hour. 

In  some  cases  of  intestinal  colic  there  is  accompanying  vomiting, 
diarrhea,  and  flatulency.  There  is  an  absence  of  any  local  rigidity 
and  tenderness  and  the  pains,  if  present,  are  more  diffuse. 

Intestinal  Obstruction. — In  the  first  twenty-four  to  forty-eight  hours 
there  is  no  difficulty  in  distinguishing  this  condition  from  appendicitis. 
When,  however,  peritonitis  has  begun  and  caused  a  septic  paralysis  of 
the  intestines,  it  is  impossible  to  distinguish  them,  except  from  the 
history. 

In  intestinal  obstruction,  if  there  is  any  localized  pain,  it  is  referred 
to  the  umbilicus.  A  systematic  examination  of  the  hernial  openings 
often  reveals  the  cause  of  the  obstruction.  Volvulus  pains  are  referred 
to  the  left  side  of  the  abdomen  and  early  distention  of  this  half  of 
the  abdomen  is  most  marked.  Obstruction  from  volvulus,  tumors, 
and  bands  is  more  common  in  adults.  In  children  intussusception  is 
more  frequent,  and  a  tumor  can  often  be  felt  per  rectum  or  in  the 


c 
3 

S    =r  3 

^     ft  CTQ 

pd     P  rt 

H   "CI  3 

W     3  O 

O     &-  '^ 


p     P3 

f^  2  3 

O    o  C 

H     &  C 

B    2.  "^ 

W     !^-  3 

^  o  2 

>   S  ^ 

t-i    j-^.  cr 

n!  fi'  p 

p  *-* 

O     3  P. 


> 


qq     p 


:^ 

rj;. 

P- 

Id 

o 

^ 

►a 

o 

W 

^ 

C^ 

Z 

n 
o 

P 

d 
>< 

2 

3 

3^ 

(73 

H 

ro 

O 

> 

CL 

w 

g 

5 

a 

< 

S 

c 

p 

Z 

O 

n 

3 

o 

~    p 


&    > 


O        P         O  HH 


f 

D- 

c 

> 

u> 

o 

en 

f3 

ni 

CAl 

o 

3 

c 

3" 

> 

O 

2 

H 

O 

C 

en 

P 

O 

O 

?^ 

CA 

c 

O 

1/. 

'-d 

r 
1^ 

c-a 

g 

> 

5' 

3 

W 
o 

p 

3 

--1 

o 

p 

o 

2.    g 


APPENDICITIS.  261 

iliac  fossae,  and  blood  and  mucus  are  passed  per  rectum.  In  obstruc- 
tion the  pulse  is  but  little  higher  than  normal  until  peritonitis  occurs, 
while  in  appendicitis  there  is  a  gradual  rise  of  pulse  and  temperature 
from  the  beginning.  The  early  nausea  and  vomiting  of  obstruction 
recur  so  frequently  as  to  become  the  most  prominent  symptom.  The 
bowels  cannot  be  moved  nor  can  flatus  be  passed,  and  the  abdominal 
distention  occurs  in  greater  degree,  as  well  as  much  earlier,  than  in 
appendicitis.  In  appendicitis  vomiting  occurs  quite  early,  is  never 
stercoraceous,  does  not  recur  until  peritonitis  sets  in,  and  constipation  is 
never  absolute. 

Typhoid  Fever. — In  the  first  two  weeks  of  certain  cases  of  typhoid 
there  is  rigidity  and  tenderness  of  the  right  iliac  region,  accompanied 
by  fever.  In  the  absence  of  a  good  previous  history  such  cases  are 
apt  to  impress  one  as  being  an  appendicitis.  As  a  rule,  however,  a 
differentiation  is  possible.  The  pain  and  rigidity  are  never  as  marked 
in  typhoid  as  in  appendicitis;  the  pulse  is  out  of  proportion  too,  being 
much  slower  than  in  appendicitis.  In  addition,  there  is  a  leukocytosis 
in  appendicitis  and  a  leukopenia  in  typhoid.  The  Widal  reaction  is 
characteristic  of  typhoid  and  is  absent  in  appendicitis  unless  the  patient 
has  had  a  previous  attack  of  typhoid.  If  a  history  can  be  obtained, 
it  reveals  the  fact  that  the  disease  has  been  gradual  in  onset,  accompanied 
by  headache,  backache,  lassitude,  and  often  by  epistaxis.  The  enlarge- 
ment of  the  spleen  and  the  steady  rise  of  temperature  with  a  relatively 
low  pulse-rate  are  characteristic  of  typhoid. 

The  differential  diagnosis  between  typhoid  perforation  and  appen- 
dicitis is  referred  to  on  page  269. 

Gastric  Ulcer. — This  is  usually  preceded  by  a  history  of  long-contin- 
ued pains  referred  to  some  particular  spot  in  the  epigastrium,  increased 
by  the  taking  of  food  and  often  accompanied  by  hematemesis  or  melena. 
The  majority  of  gastric  ulcers  occur  in  young  women  who  are  anemic 
and  have  had  sedentary  occupations.  The  examination  of  the  stomach 
contents  shows  an  increased  amount  of  hydrochloric  acid. 

Duodenal  Ulcer. — There  is  a  history  of  long  duration  of  pain,  oc- 
curring in  middle-aged  men,  -two  or  three  hours  after  eating.  The 
pain  is  felt  in  the  epigastrium,  but  may  be  referred  to  the  shoulder 
or  to  the  right  iliac  region. 

The  principal  diagnostic  points  of  perforating  gastric  and  duo- 
denal ulcers  are  discussed  on  pages  266  and  267.  A  perforating 
gastric  ulcer  can  be  diagnosed  from  the  previous  history,  from  the 
location  of  the  pain,  and  from  the  presence  of  rigidity  in  the  epigas- 
trium.    The  symptoms  of  collapse  and  the  increase  in  pulse-rate  are 


262 


THE    ABDOMEN. 


much  more  marked  than  in  appendicitis.  The  respiration  is  rapid 
and  costal  in  type.  In  perforating  duodenal  ulcer  the  pain  is  not  so 
typical  in  its  location  and  is  often  referred  to  the  right  iliac  region, 
but  there  is  no  rigidity  in  this  location,  as  in  an  appendicitis. 

When,  after  the  perforation  of  a  gastric  or  duodenal  ulcer,  perito- 
nitis has  occurred,  and  the  septic  fluid  collects  in  the  iliac  fossa  and  pelvis, 
causing  tenderness  and  rigidity,  accompanied  by  abdominal  distention, 

vomiting,  increased 
pulse-rate,  and  leuko- 
cytosis, a  differentia- 
tion from  appendicitis 
is  impossible,  except 
from  the  previous  his- 
tory. 

A  cute  Ch  olecystitis . 
— The  pain  in  this  con- 
dition, whether  due  to 
gallstones  or  not,  is 
localized  in  the  right 
upper  quadrant,  as  a 
rule,  rather  than  in  the 
right  lower,  as  in  ap- 
pendicitis. The  pain 
is  usually  more  cutting 
in  character  and  radi- 
ates to  the  right  shoul- 
der. Muscular  rigid- 
ity and  tenderness  are 
most  marked  over  the 
junction  of  the  right 
rectus  and  the  costal 
arch.  There  is  often 
also  a  history  of  pre- 
vious attacks,  accompanied,  in  some  cases,  by  shght  or  marked  jaundice 
(the  latter  if  common-duct  calcuK  are  present),  early  and  repeated 
vomiting,  and  chills  if  an  infection  of  the  bile-passages  has  existed. 

In  some  cases  a  tender  tumor,  corresponding  to  the  gallbladder, 
can  be  outlined  by  both  percussion  and  palpation  (Fig.  173). 

There  are  cases,  such  as  those  referred  to  later,  where  a 
differentiation  between  cholecystitis  and  appendicitis  is  impossible. 
These  are  where  the  gallbladder  is  at  a  lower  level  than  normal.     If 


Fig.  173. — Localized  Pain  and  Rigidity  in  Normally  Located 
AND  Displaced  Gallbladder. 
N,  Normal  position  of  gallbladder  and  liver;  the  black  arrow 
indicates  the  most  frequent  direction  of  radiation  of  pain  to  the  right 
shoulder;  H,  location  of  pain,  etc.,  in  descended  Uver;  E,  ensiform 
process;  GP,  location  of  pain  and  rigidity  in  abscesses  of  the  left  lobe 
of  the  liver. 


APPEXDICTIS.  263 

due  to  an  elongated  Riedel's  lobe  (Fig.  162),  the  resistant  mass  of  liver 
tissue  can  often  be  felt  through  the  thin  and  flabby  abdominal  walls. 
Similarly,  one  can  outline  a  descended  liver  in  some  cases  (Fig.  173). 

If  pus  form  in  the  gallbladder  (empyema),  the  rigidity  and  tender- 
ness are  higher  up  than  in  appendicitis.  However,  leukocytosis  and 
the  existence  of  a  tender  mass  in  the  right  upper  quadrant  may  lead 
to  some  confusion  with  appendicitis  complicated  by  abscess  formation  in 
an  appendix  located  high  up  (Fig.  171). 

Acute  Inflammation  of  the  Female  Adnexa. — This  can  be  best  under- 
stood by  a  reference  to  the  follo^nng  table: 

Acute  Appendicitis.  Acute  Salpixgooophoritis. 

1.  Muscular  rigidity  marked.  i.  But  little  rigidity. 

2.  Pain  begins  at  umbilicus  and  becomes       2.  Pain  lower  down  in  abdomen  just  above 

localized   over   McBurney's   point  Poupart's  ligament, 

unless  appendix  points  to  pelvis. 

3.  Tenderness  over  right  iliac  fossa.  3.  Tenderness  low  down  over  pehds. 

4.  Pain  followed  in  a  few  hours  by  nausea  4.  Nausea  and  vomiting  infrequent. 

and  vomiting. 

5.  Bimanual  examination  negative  unless       5.  Bimanual  examination  shows  tender  mass 

appendix  in  pelvis,  then  tender  mass  lateral  to  or  behind  uterus, 

lateral  to  uterus. 

6.  No  history  of  gonorrheal  infection.  6.  Usually  history  of  infection  to  be  obtained. 

When  acute  appendicitis  occurs  during  the  course  of  an  acute 
inflammation  of  the  female  pelvic  organs,  a  differentiation  is  impossible, 
except  that  the  pain  is  most  intense  over  ]\IcBumey's  point. 

Other  conditions  from  which  appendicitis  must  be  differentiated  are: 

1.  Renal  and  ureteral  coKc  (page  270). 

2.  Pyonephrosis  (page  252). 

3.  Pelvic  inflammatory  conditions  in  women. 

4.  Acute  pancreatitis  (page  270). 

5.  "Twisted  pedicles  of  ovarian  and  uterine  tumors  (page  273). 

6.  Abdominal  crises  due  to  ^leckel's  diverticulum  (page  279). 

7.  Torsion  of  the  spermatic  cord  of  a  normal  or  undescended 
testis  (page  274). 

8.  Inflammation  of  the  intraabdominal  portion  of  the  vas  deferens 
(page  276). 

9.  Embolism  and  thrombosis  of  the  mesenteric  vessels  (page  272). 

10.  Acute  pleural  or  pulmonary  inflammation  (page  276). 

11.  Dietl's  crises  due  to  the  kinking  of  the  ureter  in  movable  Iddney 
(page  271). 


264  THE    ABDOMEN. 


2.  GALLSTONE  COLIC. 

One  of  the  most  frequent  acute  abdominal  conditions  is  that  \Yhich 
is  due  to  biliar)'  calcuH. 

Diagnosis. — Paiti  and  Tenderness. — This  is  of  an  excruciating 
character,  exceeding  in  severity  that  due  to  ahnost  even.'  other  acute 
abdominal  condition.  It  is  the  result  of  two  factors.  The  first  of  these 
is  the  acute  cholecystitis  resulting  from  infection.  This  pain  of  the 
acute  cholecystitis  is  less  severe  than  the  second,  or  pain  due  to  the 
muscular  spasm  of  the  cystic  or  common  duct.  This  second  factor  is 
the  chief  cause  of  the  pain  in  bilian-  colic. 

The  pain  is  felt  in  the  right  hypochondrium  and  epigastrium,  radiat- 
ing usually  to  the  right  and  rarely  to  the  left  shoulder.  In  some  cases 
the  pain  radiates  toward  the  right  ihac  region,  simulating  that  of  appen- 
dicitis. 

The  entire  region  between  the  right  costal  arch  and  umbilicus 
is  extremely  sensitive  to  pressure  during  the  attack.  If  the  hver  is  at 
a  lower  level  or  there  is  an  elongated  Riedel  lobe,  the  pain,  tenderness, 
and  rigidity  may  be  at  the  level  of  the  umbihcus  or  even  in  the  right 
iliac  region  itself. 

Muscular  Rigidity. — This  is  most  marked  in  the  right  hypochon- 
drium, but  may  be  at  a  lower  level  if  the  gallbladder  is  in  an  abnormal 
position  (see  Fig.  173). 

Vomiting. — This  is  an  early  symptom,  consisting  at  first  of  mucus, 
later  of  bile.  It  is  present  almost  from  the  moment  of  the  onset  of  the 
pain  and  recurs  frequently  during  the  attack. 

Jaundice. — If  present  at  all,  it  occurs  only  to  a  shght  degree,  in  the 
majority  of  cases  of  gallstone  coUc,  due  to  the  passage  of  a  calculus 
through  the  cystic  duct.  Often  it  can  be  best  seen  in  the  sclerae  and  on 
the  roof  of  the  mouth.  When  present  in  marked  degree  it  signifies 
the  passage  of  a  stone  through  the  common  duct. 

Fever. — In  the  majority  of  cases  there  is  a  rise  of  temperature  in 
gallstone  colic,  due  to  the  accompanying  cholecystitis.  If  the  tempera- 
ture and  other  inflammatory  symptoms  continue  after  the  pain  has 
subsided,  an  empyema  of  the  gallbladder  is  to  be  suspected.  If  the 
gallstone  colic  is  accompanied  by  repeated  chills,  followed  by  a  marked 
rise  of  temperature  and  a  sweat,  there  is  probably  a  complicating 
cholangitis. 

The  finding  of  gallstones  in  the  stools  is,  of  course,  positive  evidence 
of  the  attack  having  been  one  of  bihar}'  colic. 

Differential  Diagnosis. — Acute  Cholecystitis. — Acute  inflammation 


GALLSTONE    COLIC.  265 

of  the  gallbladder  due  to  causes  other  than  calculi  produces  less  severe 
pain  than  a  biliary  colic.  The  abdominal  rigidity  and  tenderness  is 
not  so  marked,  so  that  the  enlarged  gallbladder  can  often  be  outlined 
by  percussion  and  palpation.  There  is,  however,  no  means  of  distin- 
guishing absolutely  a  cholecystitis  due  to  calculi  and  one  not  due  to  a 
simple  infection  or  a  catarrhal  condition.  In  the  majority  of  cases  it  is 
the  result  of  calculi. 

Renal  Colic. — In  renal  colic  the  pain  usually  begins  in  the  back 
over  the  kidney  and  radiates  down  the  ureter  toward  the  testis  and 
thigh  of  the  same  side.  The  kidney  is  tender  on  palpation  and  the 
urine  contains  blood  and  often  pus,  but  is  free  from  bile. 

Appendicitis. — There  is  no  initial  rise  of  temperature,  the  latter 
usually  appearing  after  a  few  hours.  The  vomiting  in  biliary  colic 
immediately  follows  the  onset,  and  not  after  a  few  hours,  as  in  appen- 
dicitis. It  is  also  more  frequent  during  the  continuance  of  the  pain  in 
biliarv-  colic.  The  pain  in  the  latter  is  more  severe  than  in  appendicitis, 
is  located  higher  in  the  abdomen,  as  a  rule,  and  radiates  to  the  right 
shoulder.  The  muscular  rigidity  and  tenderness  are  also  higher, 
being  most  marked  just  beneath  the  costal  arch.  Appendicitis  and 
cholelithiasis  at  times  coexist,  so  that  the  clinical  picture  is  a  most 
confusing  one. 

DietVs  Crises  and  Floating  Kidney. — A  floating  kidney  may  cause 
biliary  colic,  jaundice,  and  vomiting;  symptoms  of  compression  of 
the  portal  vein  usually  coexist.  K  diagnosis  can  be  made  only  if 
the  symptoms  cease  when  the  kidney  has  been  felt  and  is  replaced. 

Attacks  of  severe  colic,  nausea,  and  vomiting  may  occur  when  the 
ureter  is  kinked,  through  the  sudden  descent  of  a  movable  kidney. 
The  differentiation  from  gallstones  may  be  made  from  the  fact  that  the 
pain  radiates  along  the  ureter  and  the  kidney  is  tender  and  swollen  for 
some  hours  after  the  attack.  Often  its  cessation  is  followed  by  a 
largely  increased  urinary  flow. 

Gastric  and  Duodenal  Ulcers.- — The  pain  of  a  gastric  or  duodenal 
ulcer  is  never  as  severe  as  that  of  biliary  colic  and  it  can  be  more  accur- 
ately localized  in  the  epigastrium.  It  begins  soon  after  eating  in  the 
case  of  gastric,  and  two  to  three  hours  later,  in  that  of  duodenal  ulcer. 
There  is  no  rigidity  or  tenderness  over  the  right  hypochondrium  and 
no  rise  of  temperature. 


266  THE    ABDOMEN. 

3.  PERFORATIONS   OF    ULCERS   OF    THE    STOMACH   OR  DUODENUM. 

The  diagnosis  of  perforations  of  ulcers  in  these  viscera  can  be  made 
in  the  first  twelve  hours  if  the  previous  history  is  considered  in  connec- 
tion vvnth  the  acute  symptoms.  In  90  per  cent,  of  perforating  gastric 
ulcers  there  is  a  history  of  symptoms  referable  to  ulcer  of  the  stomach 
or  duodenum,  according  to  Brunner.^ 

Perforating  gastric  ulcer  is  more  frequent  in  women  (4  to  i),  while 
perforating  duodenal  ulcer  occurs  oftener  in  men  (10  to  i).  Duodenal 
ulcer  perforates  twice  as  often  as  gastric  ulcer. 

The  symptoms  in  the  majority  of  cases  are  so  typical  that  a  diag- 
nosis can  be  made  from  the  following  symptoms,  taken  in  conjunction 
with  the  previous  history: 

Pain. — In  over  95  per  cent,  of  the  cases  the  pain  occurs  suddenly 
and  is  very  severe  and  stabbing  in  character,  so  that  the  patients  cry 
out,  drawing  up  their  limbs,  and  often  become  faint.  The  pain  is  at 
first  localized  by  the  patient  in  the  epigastrium,  but  later  it  becomes 
more  diffuse. 

The  point  of  greatest  tenderness  in  five-sixths  of  the  cases  of  gastric 
ulcer  corresponds  to  the  point  of  spontaneous  or  subjective  pain;  w^hile 
in  duodenal  ulcer  the  tenderness  is  in  the  right  iliac  fossa  in  the  majority 
of  cases. 

Muscular  Rigidity. — This  symptom,  as  in  perforations  of  other 
viscera,  is,  when  associated  with  pain,  of  great  diagnostic  importance. 
As  elsewhere  explained,  it  can  be  found  by  passing  the  fingers  lightly 
over  the  abdomen  and  not  by  violently  prodding.  The  abdomen  is 
board-hke  and  often  retracted  until,  after  six  to  twelve  hours,  the  tym- 
pany, due  to  beginning  peritonitis,  causes  it  to  become  gradually  dis- 
tended. 

Vomiting. — This  occurs  in  about  one-third  of  the  cases,  and,  as 
in  appendicitis,  if  associated  with  pain  and  rigidity  is  of  great  diagnostic 
value.  Vomiting  which  occurs  after  the  first  twenty-four  hours  is  usually 
indicative  of  peritonitis.  Vomiting,  as  an  early  sign,  follows  perforations 
of  duodenal  ulcers  far  more  constantly  than  that  of  gastric  ulcers. 

Obliteration  of  Liver  Dullness. — This  symptom  is  so  inconstant 
that  but  little  reliance  can  be  placed  upon  its  presence  or  absence. 
Liver  dullness  is  apt  to  be  diminished  or  absent  through  tympanites, 
so  that  the  sign  is  of  little  value.  If  the  abdomen  is  not  distended  and 
there  is  no  liver  dullness  to  be  found,  it  is  of  value  taken  in  conjunction 
with  the  localized  pain,  rigidity,  tenderness,  and  vomiting. 

^  "Deutsche  Zeitschrift  f.  Chirurgic,"  Bd.  Ixix. 


PERFORATIONS  OF  ULCERS  OF  THE  STOMACH  OR  DUODENUM.        267 

Dullness  in  the  Flanks  and  Right  Iliac  Region. — A  shifting  area  of 
dullness  found  in  the  flanks  within  the  first  twelve  to  twenty-four  hours 
is  of  value  as  indicating  free  fluid.  Even  this  symptom  is  apt  to  be 
misleading,  and,  as  in  the  case  of  the  above  symptoms,  too  much  reli- 
ance should  not  be  placed  upon  it,  owing  to  the  fact  that  intestinal 
coils  filled  with  fluid  feces  may  give  the  same  signs. 

Pulse. — This  remains  unchanged  in  many  cases  until  peritonitis 
begins,  when  it  gradually  becomes  more  rapid  and  jerky.  In  other 
cases  it  is  rapid,  feeble,  and  irregular  from  the  beginning. 

Respiration  and  Fades. — From  the  moment  of  perforation  the 
breathing  is  almost  entirely  costal,  shallow,  and  quick,  in  the  effort 
to  avoid  movement  of  the  upper  abdominal  regions.  The  face  and 
extremities  are,  in  the  majority  of  cases,  pale,  cold,  and  clammy;  the 
eyes  sunken  and  the  expression  of  the  face  one  of  great  anxiety.^ 

Differential  Diagnosis  between  Perforation  of  Gastric  and 
of  Duodenal  Ulcer. — In  deciding  whether  the  perforation  is  due  to  a 
gastric  or  duodenal  ulcer,  the  following  facts  must  be  taken  into  con- 
sideration. 

The  majority  of  cases  of  duodenal  perforation  occur  in  men,  espe- 
cially alcoholics;  the  seat  of  the  initial  pain  and  point  of  greatest  ten- 
derness is  to  the  right  of  the  median  line;  often  the  tenderness  is  most 
marked  in  the  right  iliac  region.  There  is  not  nearly  so  frequently 
a  previous  history  of  preceding  digestive  disturbances  as  in  gastric 
ulcer.  A  previous  history  of  tarry  stools  and  the  occurrence  of  vomiting 
and  pain  a  long  time  after  eating,  suggest  duodenal  ulcer. 

In  perforation  of  a  gastric  ulcer,  the  spontaneous  pain  and  area  of 
greatest  tenderness  are  almost  always  in  the  epigastrium.  Gastric  ulcers 
occur  more  often  in  women  about  the  age  of  twenty,  with  a  prior  history 
of  digestive  disturbance,  pain  soon  after  eating,  and  not  infrequently  of 
hematemesis.  It  is  almost  impossible  to  accurately  locate  the  exact 
seat  of  the  gastric  perforation. 

Differential  Diagnosis  between  these  Perforations  and  Other 
Acute  Abdominal  Conditions. — Perforations  of  the  stomach  from 
carcinoma,  perforation  of  the  gallbladder,  and  perforation  of  a  tuber- 
culous ulcer  of  the  intestine  are  so  rare  that  they  need  only  to  be 
mentioned. 

Appendicitis. — This  is  the  greatest  source  of  error  and  is  fully 
-considered  on  page  256.     The  pain  in  gastric  ulcer  perforations  differs 

'In  subacute  perforations,  i.  e.,  those  occurring  so  slowly  that  a  walling  off  is  possi- 
ble, as  first  described  by  Moynihan,  all  of  these  symptoms  are  present,  but  in  far  less 
marked  degree. 


205  THE    ABDOMEN. 

in  its  seat  from  that  of  appendicitis,  while  that  of  many  cases  of  duodenal 
ulcer  more  nearly  coincides  with  that  of  appendicitis  in  being  situated 
in  the  right  iliac  region. 

In  appendicitis  the  rigidity  is  more  localized  in  the  right  iliac  region, 
and  there  is  seldom  a  history  of  digestive  disturbances  or  of  pain  after 
eating  or  hemorrhage  from  the  stomach  or  bowels. 

Gastralgia. — There  are  no  objective  symptoms.  The  pain  is 
relieved  by  pressure,  has  been  present  on  previous  occasions,  does  not 
last  as  long,  and  occurs  in  neurotic  persons.  There  is  no  history  of 
hematemesis  or  of  melena. 

Angina  Sclerotica  Abdominis. — This  relatively  rare  condition  has 
been  mistaken  for  perforation.  In  both  there  is  sudden  onset  of  pain, 
quick  pulse,  and  collapse,  but  in  angina  the  pain  is  higher  and  passes 
off  more  quickly. 

Gallstone  Colic. — The  pain  is  less  severe  and  not  so  sudden,  is 
conjSned  to  the  gallbladder  region,  radiates  to  the  right  shoulder,  there 
are  often  chills  and  rise  of  temperature.  The  colic  attacks  pass  away 
or  the  pain  is  intermittent.  The  gallbladder  can  often  be  palpated 
and  there  is  often  a  previous  history  of  similar  attacks.  The  other 
conditions  from  which  these  perforations  must  be  differentiated  are 
discussed  elsewhere  in  this  chapter.  They  are:  Acute  pancreatitis 
(page  270);  thoracic  affections  (page  276);  embohsm  and  thrombosis 
of  the  mesenteric  artery  (page  272),  etc.,  lead  poisoning,  renal  cohc, 
and  torsion  of  abdominal  tumors. 

TYPHOID  PERFORATION. 

Perforations  of  typhoid  ulcer  usually  occur  in  the  third  week  of  the 
disease.  The  diagnosis  in  the  majority  of  cases  can  be  made  by  careful 
observation  of  a  sudden  change  in  the  patient's  condition,  accompanied 
by  sharp  pain  in  the  right  ihac  region,  muscular  rigidity,  tenderness, 
and  a  sudden  rise  in  pulse-rate  and  respiration. 

In  patients  who  are  apathetic  all  of  these  symptoms  are  apt  to  be 
overlooked,  and  the  first  signs  which  will  call  attention  to  the  possibihty 
of  a  perforation  are  the  change  in  the  expression  of  the  face,  rigidity 
and  tenderness  of  the  abdomen,  gradually  becoming  diffuse,  the  rise 
in  pulse-rate  and  the  appearance  of  tympanites. 

The  same  may  be  said  to  be  true  for  typhoid  perforations  in  children 
where  collapse,  severe  abdominal  pain,  uncontrollable  vomiting,  ten- 
derness, and  distention  are  all  much  less  marked  than  in  adults. 

Another  condition  which  may  prevent  making  an  early  diagnosis  in 


PERFOILA.TIOXS    OF   ULCERS    OF   THE    STOMACH    OR   DUODENUM.    269 

typhoid  perforation  is  to  be  found  in  the  distention  of  the  abdomen 
which  not  infrequently  accompanies  the  more  severe  cases. 

If  a  diagnosis  of  perforation  has  not  been  made  from  the  charac- 
teristic pain,  muscular  rigidity,  and  tenderness  of  the  right  ihac  region, 
accompanied  by  an  increased  pulse-rate,  fall  of  temperature  and  collapse, 
then  a  diagnosis  must  be  made  from  the  S}Tiiptoms  of  beginning  perito- 
nitis. These  are,  in  such  cases,  general  abdominal  tenderness  and 
rigidity,  repeated  vomiting,  and  gradually  increasing  abdominal  dis- 
tention, if  the  latter  has  not  existed  before  the  onset  of  the  pain.  The  loss 
of  liver  dullness  is  so  inconstant  a  symptom  as  to  be  of  little  value  in 
making  a  diagnosis  of  perforation.  In  many  cases  the  blood-count 
may  be  of  aid,  frequently  the  normal  leukopenia  of  typhoid  being 
replaced  by  a  gradually  increasing  leukocytosis. 

Differential  Diagnosis. — Hemorrhage. — The  symptoms  of  hem- 
orrhage from  a  typhoid  ulcer  of  the  ileum  may  simulate  those  of  per- 
foration and  the  two  may  coexist.  Both  produce  symptoms  of  collapse, 
such  as  sweats,  rapid  pulse  and  respiration,  sunken  eyes,  etc.  But 
hemorrhage  is  not  attended  by  such  marked  pain,  tenderness,  or  rigidity 
in  the  right  ihac  region,  and"  in  an  hour  or  two  blood  is  passed  with  the 
bowel  movement.  If  there  is  no  reaction  from  the  collapse  symptoms, 
and  abdominal  tenderness,  rigidity,  and  distention  begin  to  appear, 
the  case  should  be  looked  upon  as  one  of  perforation,  either  accom- 
panied by  or  independent  of  hemorrhage,  as  the  case  may  be. 

Appendicitis. — Vomiting  is  more  apt  to  accompany  the  initial  pain 
in  appendicitis,  and  there  is  not  apt  to  be  such  an  amount  of  collapse 
in  the  early  hours  of  an  attack  as  is  the  case  in  intestinal  perforation. 

Cholecystitis. — This  usually  occurs  at  a  somewhat  earlier  period 
in  the  course  of  typhoid  than  does  a  perforation,  and  is  accompanied 
by  the  characteristic  pain,  muscular  rigidity,  and  tenderness  just  below 
the  costal  arch,  and  not  over  the  right  ihac  region.  There  is  also  at 
times  a  mass  to  be  palpated  or  dullness  to  be  elicited  at  an  early  stage. 

Suppurating  Mesenteric  Glands. — Every  case  described  during  the 
past  few  years  of  suppuration  and  rupture  of  the  mesenteric  glands 
occurring  during  typhoid  and  simulating  perforation,  has  had  symptoms 
of  pain,  collapse,  rapid  pulse,  etc.  The  muscular  rigidity,  however,  is 
not  so  well  localized,  as  a  rule,  in  the  right  ihac  region,  nor  are 
general  abdominal  tenderness  and  distention  so  hkely  to  follow,  as  in 
genuine  typhoid  perforation. 


270  THE   ABDOMEN. 

■    4.  ACUTE  PANCREATITIS. 

The  occurrence  of  sudden  severe  pain  in  the  epigastrium,  accom- 
panied by  symptoms  of  collapse  and  by  vomiting,  should  lead  one  to 
diagnose  an  acute  pancreatitis,  if  the  other  acute  conditions  which 
occur  in  the  upper  abdominal  region  can  be  excluded. 

In  addition  to  the  above  triad  of  symptoms,  there  is  muscular 
rigidity  and  tenderness  over  the  epigastrium,  and  when  in  two  or  three 
days  this  subsides  somewhat,  a  tender  mass  can  be  felt  here.  If  sup- 
puration occurs  a  rise  of  temperature  persists  after  the  subsidence  of 
the  acute  symptoms,  and  with  it  a  leukocytosis.  In  many  cases,  how- 
ever, death  occurs  on  the  second  to  fourth  day  of  the  disease.  In  the 
acute  cases  there  is  marked  constipation,  but  this  is  not  so  absolute 
but  that  flatus  can  be  passed  by  the  aid  of  an  enema.  There  is  also  fat 
in  large  quantities  in  the  stools. 

There  is  a  subacute  form  in  which  the  symptoms  are  all  less  violent. 
There  is  a  constant  dull  epigastric  pain,  loss  of  flesh,  and  the  vomiting 
is  less  severe.  There  is  diarrhea  instead  of  constipation,  pus  and  blood 
appearing  in  the  fetid  stools."  If  an  abscess  has  developed  there  is  a 
very  tender  epigastric  tumor  accompanied  by  chills  and  fever. 

Differential  Diagnosis. — Biliary  Co/fc— The  symptoms  of  this 
at  times  precede  those  of  acute  pancreatitis  in  many  cases. 

Phlegmonous  Gastritis. — This  is  a  rare  condition,  but  very  acute  and 
fatal.  The  symptoms  are  very  much  the  same  as  those  of  an  acute 
pancreatitis,  but  the  pain  is  not  as  severe;  there  is  high  fever  and  early 
signs  of  general  peritonitis.  The  onset  is  more  gradual  and  the  vomitus 
contains  pus  and  blood. 


5.  RENAL  COLIC. 

Symptoms. — In  a  typical  case  the  pain  is  intense,  causes  faintness 
and  collapse  symptoms,  such  as  feeble,  rapid  pulse,  cold,  clammy  skin 
and  extremities.  The  pain  is  paroxysmal  and  begins  usually  in  the 
back  over  the  kidney,  radiating  along  the  ureter  to  the  testis  or  labia 
and  thigh. 

At  the  onset,  in  addition  to  the  pain  and  collapse,  there  is  often 
a  chill  and  vomiting.  The  attack  may  last  three  to  five  days  and  then 
suddenly  subside. 

The  urine  during  the  attacks  contains  blood,  which  can  at  times 
only  be  found  by  the  aid  of  the  microscope.  Frequency  of  micturition 
accompanies   the   attacks.     The   passage   of   the   calculus    during   or 


dietl's  crises. 


271 


shortly  after  the  attack  is  confirmatory  evidence.  Should  the  calculus 
slip  back,  or  should  the  attack  be  due  to  a  twisted  ureter,  an  unusual 
amount  of  urine  often  follows  the  subsidence  of  the  pain. 

The  diagnosis  of  atypical  cases  of  renal  coKc  and  the  diagnosis  of 
renal  calculus  in  general 
are     discussed    on    page 

365- 


6.  DIETL'S  CRISES. 

These  are  attacks  of 
acute  abdominal  pain,  first 
described  by  von  Dietl  of 
Vienna,  accompanied  by 
nausea,  a  chill,  and  vomit- 
ing which  are  the  result  of 
the  kinking  or  bending 
upon  itself  of  the  ureter  in 
movable  kidney  (Fig.  174). 
The  pain  may  be  quite 
severe  and  usually  radiates 
along  the  ureter,  as  in  renal 
colic.  During  the  attack 
the  kidney  is  sw^ollen  and 
tender,  this  condition  last- 
ing several  hours.  In  some 
cases  a  distinct  hydrone- 
phrosis develops  during 
the  attacks.  Blood  is 
present  in  the  urine  only 
after  the  attack  has  sub- 
sided, and  is  accompanied 

by  polyuria,  while  during  the  attack  there  is  diminished  secretion  of 
urine. 

The  diagnosis  may  be  made  from  the  palpation  of  the  swollen,  tender, 
displaced  kidney,  and  the  fact  that  when  it  is  replaced  the  symptoms 
cease. 

^     There  is  but  little  abdominal  rigidity,  no  fever  or  leukocytosis,  and 
the  condition  occurs  most  frequently  in  muciparous  women. 

Differential  Diagnosis. — Renal  Colic  Due  to  Calculi. — In  renal 
colic  due  to  calculi  the  symptoms  of  pain  radiating  along  the  ureter, 


Fig.  174. — Lateral  View  of  Relations  in  Intermittent 
Hydronephrosis  Occurring  in  a  Floating  Kidney, 
Due  to  Kinking  of  the  Ureter. 

H,  Enlarged  kidney.  Note  the  kinking  of  the  ureter.  (This 
is  the  cause  of  the  symptoms  in  Dietl's  crises.) 


272  THE    ABDOMEN. 

nausea,  vomiting,  etc.,  are  the  same  as  in  Dietl's  crises.  The  pain,  how- 
ever, is  much  more  severe  and  apt  to  be  accompanied  by  symptoms 
of  collapse,  such  as  cold,  clammy  sweat,  rapid  pulse,  etc.  There  is 
also  blood  in  the  urine  during  the  attacks,  while  in  kinking  of  the  ureter 
it  is  only  present  at  the  end  of  the  attacks. 

If,  however,  the  attacks  of  kinking  of  the  ureter  follow  in  rapid 
succession,  blood  is  found  in  the  urine  all  of  the  time  and  a  differentiation 
is  very  difficult.  Renal  coHc  is  less  apt  to  be  accompanied  by  enlarge- 
ment of  the  kidney. 

Gallstones. — The  pain  is  located  higher  up  in  the  abdomen,  is  much 
more  severe,  and  there  is  rigidity  and  tenderness  over  the  region  of  the 
gallbladder.  The  pains  radiate  to  the  shoulder.  If  the  patient  is 
laid  on  the  left  side,  the  movable  kidney  can  be  more  distinctly  palpated 
because  the  gallbladder  rolls  away. 


Fig.    175. — Prominence    of    Abdomen  as    Result  of  Tympanites    following    Thrombosis    of    the 
Superior  Mesenteric  Artery  in  a  Woman  with  a  Pendulous  Abdomen. 


7.  EMBOLISM  AND  THROMBOSIS  OF  THE  MESENTERIC  VESSELS. 
An  acute  abdominal  condition  which  is  far  more  frequent  than  was 
formerly  thought  follows  the  occlusion  of  the  mesenteric  vessels  (Fig. 

176). 

Clinically  it  is  impossible  to  distinguish  embolism  of  the  superior  or 
inferior  mesenteric  artery  from  thrombosis  of  the  mesenteric  veins. 

Both  conditions  produce,  as  a  rule,  very  acute  symptoms.  In  some 
cases  they  resemble  those  of  intestinal  obstruction;  in  another  class  of 
cases,  peritonitis  is  simulated. 

Embolism  occurs  in  both  sexes  after  middle  life,  secondary  to  endo- 


TORSION  OF  THE  PEDICLES  OF  OVARIAN  AND  UTERINE  TUMORS.    273 

carditis  or  to  atheroma  of  the  mesenteric  vessels.  Thrombosis  may  be 
primary,  following  acute  infective  processes,  especially  of  the  appendix.  It 
may  occur  secondary  to  any  hepatic  condition  which  causes  portal  stasis. 

In  but  few  cases  has  it  been  possible  to  make  a  diagnosis,  nor  is  this 
absolutely  necessary,  since  the  symptoms  are  so  acute  that  an  explor- 
atory laparotomy  is  indicated,  even  if  a  probable  diagnosis  has  only 
been  made. 

The  disease  begins  in  one  of  two  ways,  (a)  Symptoms  which  sim- 
ulate intestinal  obstruction,  with  or  without  peritonitis.  This  form 
begins  with  colicky  abdominal  pain  followed  by  nausea  or  vomiting 
and  absolute  constipation,  so  that  not  even  flatus  is  passed.  The 
abdomen  soon  becomes  so  distended,  rigid,  and  tender  that  examina- 
tion becomes  very  difficult  (Fig.  175).  (b)  Symptoms  of  hemorrhage 
from  the  intestine.  In  this  form  the  symptoms  of  early  bowel  paralysis 
are  not  so  marked,  but  there  is  great  prostration,  severe  colicky  pain, 
and  frequent  bloody  stools. 

Differential  Diagnosis. — This  is  impossible  in  the  majority  of 
cases,  except  that  embolism  occurs  after  middle  life.  It  must  be 
differentiated  from  perforations  of  gastric  and  duodenal  ulcers,  from 
acute  cholecystitis  (page  266),  appendicitis  (page  256),  etc.,  and  the 
various  forms  of  intestinal  obstruction. 


8.  TORSION  OF  THE  PEDICLES  OF  OVARIAN  AND  UTERINE  TUMORS. 

The  presence  of  such  a  tumor  may  reveal  itself  for  the  first  time 
when  the  pedicle  has  become  twisted.  The  onset  is  sudden,  with 
severe  colicky  pain  referred  to  the  pelvis,  accompanied  by  vomiting 
and  shght  muscular  rigidity.  If  the  tumor  becomes  gangrenous,  these 
primary  symptoms  are  rapidly  followed  by  those  of  a  spreading 
peritonitis.  The  rigidity  and  tenderness,  which  were  at  first  present 
in  only  the  lower  part  of  the  abdomen,  become  general.  The  pulse-rate 
increases  rapidly  and  abdominal  distention  becomes  marked,  and  the 
patient  septic. 

The  diagnosis  may  be  made  by  a  pelvic  examination  and  the  palpa- 
tion of  the  tumor  mass  and  its  pedicle.  Without  the  use  of  an  anes- 
thetic, such  examination  can  only  be  made  with  difficulty,  owing  to 
the  muscular  rigidity.  In  some  cases  a  history  of  gradual  enlargement 
of  the  abdomen,  preceding  the  acute  attack,  can  be  obtained. 

After  a  septic  paralysis  of  the  bowels  has  occurred,  the  case  cannot  be 
differentiated  from  peritonitis  due  to  other  causes,  unless  the  vaginal 
examination  shows  the  presence  of  a  tumor  and  its  pedicle. 


2  74  THE    ABDOMEN. 

Differential  Diagnosis. — Appendicitis. — In  the  early  hours,  if 
the  tumor  is  located  on  the  right  side,  there  may  be  some  resemblance. 
The  palpation  of  a  tumor  will,  however,  at  once  exclude  an  appendicitis, 
since  such  a  large  inflammatory  mass  does  not  form  in  so  short  a  time. 
Later  on  such  a  mass  may  resemble  appendicitis  with  abscess  formation, 
but  the  tumor  is  more  elastic  and  there  is  more  general  abdominal 
rigidity  and  tenderness,  as  well  as  other  symptoms  of  a  spreading  peri- 
tonitis. 


9.  TORSION  OF  THE  SPERMATIC  CORD. 

This  may  occur  in  an  imperfectly  or  in  a  normally  descended  testis 
(Fig.  232).  It  usually  follows  heavy  lifting,  etc.  The  onset  is  very 
sudden,  greatly  resembling  that  of  a  strangulated  hernia.  The  attack 
begins  with  severe  pain  in  the  region  of  the  testis,  far  greater  than  in  an 
ordinary  epididymitis,  accompanied  by  collapse,  vomiting,  constipation, 
great  local  tenderness,  and  swelling.  The  principal  condition  from 
which  it  must  be  differentiated  is  a  strangulated  hernia.  This  is  as 
follows  (Eccles) : 

Torsion  of  Cord.  Strangulated  Hernia. 

History Probable  of  strain.  Often  of  strain. 

Position  of  testis Often  imperfectly  descended.  Usually  fully  descended. 

Shock Moderate.  Often  severe. 

Vomiting Slight  and  not  persistent.  Severe  and  persistent. 

Constipation May  be  present.  Is  absolute. 

Tenseness  of  swelling Not  marked.  Marked. 

Impulse  on  coughing None.  None. 

Condition  of  cord Tender,  twisted,  and  swollen.  Not  to  be  felt. 


10.  VISCERAL  CRISES. 

These  may  occur  either  as  a  complication  of  tabes  or  of  an  angioneu- 
rotic edema. 

Those  due  to  tabes  may  at  times  be  so  severe  as  to  fully  simulate 
some  of  the  previously  named  acute  conditions,  such  as  appendicitis, 
perforation  of  ulcers,  gallstone  colic,  or  even  intestinal  obstruction. 

In  patients  at  or  above  middle  age,  especially  males,  who  have  such 
symptoms,  the  possibility  of  visceral  crises  of  tabes  must  not  be  over- 
looked, and  other  evidences  of  the  disease  searched  for. 

In  the  most  typical  cases  there  are  severe  epigastric  pains,  repeated 
vomiting,  great  prostration,  and  rapid  pulse.  The  attack  may  ter- 
minate fatally  in  a  short  time,  or  continue  for  several  hours  or  even 
for  days  and  recur  from  time  to  time. 


VISCERAL   CRISES. 


275 


Crises  are  also  associated  with  various  manifestations  of  skin 
affections  of  the  erythema  group,  and  with  attacks  of  angioneurotic 
edema.  There  is  severe  abdominal  pain  which  may  last  for  hours. 
One  case,  described  by  Osier,'  was  mistaken  for  renal  coHc.     The  pain 


Fig.  176.— Gangrene  of  a  Single  Loop  of  Small  Intestine  Due  to  Eslbolism  of  Mesenteric  Artery 

(Kenerson). 

is  sometimes  accompanied  by  nausea  and  vomiting,  in  other  cases  by 
diarrhea,  and  in  still  others  by  the  passage  of  blood. 
-     The  diagnosis  can  only  be  made  from  the  history  of  the  cutaneous 
affections   or  of   repeated   attacks   of   sudden   edematous   swelling   in 
various  parts  of  the  body. 

'"American  Jour.  :Med.  Sciences,"  Jan.  i,  1904. 


276  THE   ABDOMEN. 

n.  ANGINA  SCLEROTICA  ABDOMINIS. 
This  occurs  in  elderly  people  in  the  form  of  attacks  of  severe  pain  in 
the  epigastrium.     It  is  due  to  an  atheromatous  condition  of  the  vessels 
of  the  splanchnic  area  and  must  be  differentiated  from  lead  colic  and 

from  the  crises  of  tabes.     The  attacks  may  be  accompanied  by  diarrhea. 
The  stool  at  times  contains  large  quantities  of  blood. 

12.  REFERRED  PAIN  FROM  SPINAL  AND  THORACIC  CONDITIONS. 

Spondylitis,  and  tumors  of  the  spinal  cord,  of  its  membranes,  or  of 
the  vertebra,  may  cause  severe  abdominal  pain,  which  is  referred  to 
the  terminal  filaments  of  the  spinal  ner\'es  of  the  corresponding  segment 
in  the  abdominal  wall.  The  pain  is  seldom  as  acute  as  in  true  abdom- 
inal affections,  and  is  not  accompanied  by  muscular  rigidity  or  tender- 
ness. Examination  of  the  spine  for  evidences  of  spond^^Htis  (page  684) 
will  soon  reveal  the  nature  of  the  referred  pain.  Examination  of  the 
nen'ous  system  and  the  history  of  the  case  will  eliminate  tumors  of  the 
cord  or  spinal  column. 

Thoracic  Conditions. — Cases  of  both  pneumonia  and  pleurisy 
occur,  in  which  there  is  complaint  of  severe  pain  in  the  abdomen  at  the 
onset  of  the  disease.  This  is  especially  true  in  children.  There  may 
be  rigidity  of  the  abdominal  muscles  on  the  side  affected.  In  pneu- 
monia there  is  a  history  of  a  chill.  The  acute  onset  is  followed  by 
dyspnea,  and  marked  increase  in  respirations  and  pulse-rate.  The 
pain  is  seldom  as  well  locahzed  as  in  the  acute  abdominal  conditions, 
nor  is  the  muscular  rigidity  as  circumscribed  and  constant. 

There  is  one  form  of  pleurisy  (diaphragmatic)  which  simulates 
acute  abdominal  affections  very  closely.  The  breathing  is  shallow 
and  costal,  the  pain  is  severe  and  referred  to  the  upper  abdominal 
region,  as  in  perforations  of  gastric  and  duodenal  ulcer,  acute  pancrea- 
titis, etc. 

Objectively  but  little  can  be  found  and  a  differential  diagnosis  is 
difficult  in  the  early  hours.  The  case  should  be  watched  for  several 
hours  before  a  final  diagnosis  is  made. 


13.  INFLAMMATION  OF  THE  INTRAABDOMINAL  PORTION  OF  THE  VAS 

DEFERENS. 

Severe  pain,  of  a  coHcky  nature,  referred  either  to  the  right  or  left 

iUac  regions  is  the  initial  s}Tnptom.    It  is  later  accompanied  by  nausea 

or  vomiting,  as  a  forerunner  of  epididymitis  or  orchitis. 


ACUTE  INTESTINAL  OBSTRUCTION.  277 

When  this  condition  exists  on  the  right  side,  it  may  be  mistaken  for 
an  appendicitis.  Especially  when  it  precedes  the  orchitis  of  mumps, 
one  must  avoid  this  error. 

In  gonorrheal  cases,  the  diagnosis  may  be  made  from  the  urethral 
discharge,  which  often  ceases  suddenly  before  such  an  attack.  When 
it  follows  mumps,  the  previous  history  is  of  value. 

The  most  tender  point  is  not  over  the  middle  of  the  right  iliac  region 
(McBumey's  point),  as  in  appendicitis,  but  is  deeply  situated  over  the 
middle  of  Poupart's  ligament  or  deep  down  in  the  pelvis.  Rectal 
examination  is  of  great  aid  in  making  a  differentiation. 


Group  III. — Early  Signs  of  Intestinal  Obstruction. 
ACUTE  INTESTINAL  OBSTRUCTION  (ILEUS). 
In  every  case  before  a  definite  diagnosis  of  intestinal  obstruction 
is  made  three  points  must  be  considered: 

1.  What  symptoms  indicate  intestinal  obstruction? 

2.  What  is  the  probable  nature  and  seat  of  the  obstruction? 

3.  What  other  symptoms  might  simulate  it? 

I.  Symptoms  of  Intestinal  Obstruction. — The  most  typical  ones 
are: 

(a)  Absolute  constipation. 

(&)   Constantly  recurring  vomiting  finally  becoming  fecal. 

(c)  Pain  of  varying  intensity  and  location. 

(d)  Gradual  or  sudden  distention  of  the  abdomen. 

(e)  Gradually  increasing  pulse-rate. 

(/)    Visible  peristalsis  and  the  presence  of  a  tumor. 

(g)  Collapse  symptoms,  such  as  sunken  eyes,  anxious  face,  cyanosis, 
pallor,  dyspnea. 

//  a  patient,  suffering  jrom  a  sudden  attack  oj  abdominal  pain,  lias 
constantly  recurring  vomiting,  and  every  effort  to  secure  the  passage  of 
feces  or  flatus  results  negatively,  a  diagnosis  of  intestinal  obstruction  may 
be  made. 

The  three  symptoms  common  to  all  forms  of  abdominal  obstruc- 
tion are: 

1.  Absolute  inability  to  secure  the  passage  of  feces  or  flatus. 

2.  Vomiting  first  of  mucus,  then  of  bile,  and  lastly  of  fecal  matter. 

3.  Pain. 

Constipation  is  often  the  first  symptom.  Before  declaring  it  abso- 
lute, however,  high  rectal  enemata  should  be  given,  with  the  patient 
lying  on  his  back  with  hips  elevated.     The  fountain  syringe  or  irrigator 


278  THE    ABDOMEN. 

does  not  need  to  be  raised  more  than  three  feet  above  the  patient.  An 
ordinary  high  rectal  tube  is  inserted  almost  its  full  length,  the  fluid 
being  allowed  to  run  through  the  tube  during  its  insertion  into  the 
rectum.  The  temperature  of  the  liquid  should  never  be  above  110°  F. 
and  the  quantity  used  should  not  exceed  two  quarts  in  adults  and 
one  and  one-half  pints  in  children.  To  test  the  passage  of  flatus  most 
accurately  it  is  best  to  keep  the  outer  end  of  the  tube  under  water  and 
thus  observe  the  escape  of  bubbles  of  gas  as  they  leave  the  tube. 

If  no  morphin  has  been  given,  and  all  the  fecal  matter  below  the 
obstruction  has  been  washed  out,  and  there  is  no  escape  of  flatus  or 
feces  on  repeating  the  enema,  the  conclusion  can  be  drawn  that 
some  obstruction  either  of  adynamic  or  mechanical  nature  exists. 

The  only  exception  to  the  statement  that  absolute  constipation  is 
one  of  the  most  important  diagnostic  signs  of  intestinal  obstruction 
occurs  in  those  cases  of  intussusception  in  which  sufficient  lumen 
remains  in  the  center  of  the  invaginated  gut  to  permit  the  passage  of 
frequent  liquid  fecal  stools.  The  diagnosis  in  such  cases  must  be 
made  from  the  other  special  signs  of  intussusception,  referred  to  below. 

Vomiting. — The  most  characteristic  emesis  is  that  occurring  either 
with  or  independently  of  pain,  but  so  frequently  repeated  that  nothing 
is  retained. 

Fecal  vomiting  does  not  usually  appear  until  the  third  or  fourth 
day.  Therefore  a  diagnosis  must  be  made  at  an  earlier  period  to  be 
of  value  in  saving  the  patient's  hfe  by  operation. 

The  vomiting  which  accompanies  the  pain  of  other  acute  abdominal 
affections,  such  as  appendicitis,  is  primary,  i.  e.,  it  occurs  perhaps  once 
or  twice  within  the  first  few  hours  after  the  onset  of  pain,  but  is  not 
frequently  repeated  unless  peritonitis  sets  in. 

In  intestinal  obstruction  the  emesis  begins  rather  innocently  at 
first,  as  in  the  affections  of  Group  II,  but  constantly  recurs,  so  that 
anything  which  is  swallowed  remains  in  the  stomach  but  a  short  time. 

The  vomitus  is  at  first  composed  of  the  food  ingested  before  the 
attack  began,  mixed  with  mucus.  Later  it  consists  of  the  bihous 
vomit,  so  frequently  seen  in  acute  gastroenteritis,  though  more  fre- 
quently repeated  than  in  the  latter.  After  a  variable  time,  usually  the 
third  to  fourth  day,  it  becomes  of  a  brownish-black  color  and  of  fecal 
odor.     Emesis  is  then  almost  constant. 

Pain  as  a  diagnostic  sign  varies  greatly.  It  is  most  marked  in  ob- 
struction due  to  volvulus,  to  bands,  or  to  protrusion  through  external 
or  internal  hernial  apertures. 

There  are  cases  in  which  but  httle  pain  is  present  and  the  diagnosis 


ACUTE    INTESTINAL    OBSTRUCTION.  279 

must  be  made  from  the  absolute  constipation,  constant  vomiting,  and 
gradually  increasing  tympanites. 

The  pain  is  at  first  sharp  and  colicky  in  character.  Later  it  becomes 
more  or  less  continuous,  until,  the  paralysis  having  become  complete  on 
the  third  or  fourth  day,  pain  ceases. 

A  gradually  increasing  distention  of  the  abdomen  is  characteristic 
of  intestinal  obstruction.  Its  distribution  over  the  abdomen  varies 
according  to  the  seat  of  the  obstruction,  and  is  referred  to  in  detail 
later.  The  pulse-rate  does  not,  as  a  rule,  increase  as  steadily  as  in 
peritonitis.  In  some  forms  of  obstruction,  however,  such  as  intussus- 
ception, the  pulse-rate  is  rapid  and  weak  from  the  beginning. 

Peristaltic  waves  may,  at  times,  be  seen  traveling  in  an  opposite 
direction  from  the  normal  during  the  first  forty-eight  to  seventy-two 
hours.  This  is  to  be  seen  quite  easily  before  the  abdominal  distention 
is  too  great,  provided  there  is  not  too  much  fat  in  the  abdominal  wall. 

A  tumor  is  palpable  in  many  cases  in  which  the  acute  symptoms 
follow  those  of  chronic  stenosis  of  the  bowel,  of  long  duration.  It  can 
also  be  felt  in  cases  of  intussusception  along  the  transverse  colon,  in 
the  left  iliac  fossa,  or  per  rectum. 

The  symptoms  of  collapse  appear  gradually  in  the  majority  of 
cases,  usually  about  the  third  or  fourth  day.  Rarely,  they  appear 
suddenly,  at  an  earlier  period,  in  cases  of  volvulus. 

Probable  Nature  and  Seat  of  the  Obstruction. — Every  patient 
should  be  examined  before  operation  to  ascertain  these  facts.  Such 
examination  should  include: 

(a)  The  previous  history. 

(b)  The  physical  examination  of  the  abdomen  itself. 

(c)  Rectal  and  vaginal  examination. 

Strangulation. 

History. — Strangulation  most  frequently  occurs  in  adults  who 
have  a  previous  history  of  attacks  of  abdominal  pain,  a  previous  attack  of 
peritonitis,  an  operation  on  the  abdominal  viscera,  or  a  recognized  hernia. 
The  previous  history  may,  however,  throw  absolutely  no  light  on  the 
present  condition,  especially  in  those  cases  in  which  strangulation  by 
bands  derived  from  Meckel's  diverticulum  occurs.  The  previous 
existence  of  a  hernia  is  of  value,  since  strangulation  of  only  a  portion 
or  the  whole  of  a  coil  of  intestine  (acute  partial  enterocele)  may  give 
rise  to  the  same  symptoms  as  though  the  entire  lumen  of  the  gut  were 
obstructed. 

Abdominal  Pain. — This  is  usually  quite  severe  and  of  a  colicky 


28o  THE    ABDOMEN. 

nature.  In  the  case  of  strangulated  hernia  it  is  most  marked  in  close 
proximity  to  the  hernial  opening. 

Nausea  and  Vomiting. — These  occur  quite  early  and  are  more 
marked  in  this  form  of  intestinal  obstruction  than  in  any  other  except 
volvulus.     Vomiting  becomes  fecal  from  the  third  to  the  fifth  day. 

Constipation. — This  is  absolute  in  strangulation.  Enemata  given 
in  the  early  hours  bring  away  some  fecal  matter;  after  this  they  result 
negatively. 

Shock. — This  is  quite  marked,  as  a  rule,  although  it  may  not  appear 
until  the  second  or  third  day  of  the  obstruction. 

Examination  of  Abdomen. — The  distention  of  the  abdomen  appears 
quite  early,  being  especially  marked  in  the  central  portions  of  the 
abdomen  if  the  small  intestine  is  involved,  and  in  the  lateral  portions 
if  the  large  intestine  is  obstructed.  Peristalsis  may  be  seen  in  the  early 
hours,  through  a  thin  abdominal  wall.  It  can  often  be  artificially 
elicited  by  light  tapping  on  the  abdominal  wall. 

Volvulus. 

This  can  rarely  be  diagnosed  before  operation. 

Previous  History. — It  occurs  most  often  in  adults,  especially  those 
suffering  from  chronic  constipation.  At  times  there  is  a  history  of 
previous  attacks  of  peritonitis. 

Pain. — Pain  is  often  severe  from  the  beginning,  and  in  some  cases 
quite  accurately  localized  to  the  left  of  the  umbihcus.  It  is  very  severe 
and  colicky  in  nature. 

Nausea  and  Vomiting. — These  do  not  occur  as  early  as  in  strangu- 
lation and  the  vomitus  becomes  fecal  on  the  third  or  fourth  day. 

Constipation. — This  is  more  marked  at  an  early  period  than  in  any 
of  the  other  forms  of  obstruction,  owing  to  the  fact  that  the  large  intes- 
tine is  involved. 

Shock. — -This  does  not  occur  as  early  as  in  strangulation  or  intus- 
susception, but  may  come  on  quite  suddenly  on  the  third  or  fourth  day, 
and  be  extreme  in  character. 

Examination  of  Abdomen. — Visible,  peristalsis  may,  at  times,  be  seen 
on  the  left  side  of  the  abdomen,  beginning  at  the  point  of  obstruction 
and  traveling  upward  and  downward  along  the  line  of  the  transverse 
colon.  The  distention  of  the  abdomen  is  much  more  extensive  than 
in  obstruction  of  the  small  intestine  by  strangulation.  It  is  especially 
marked  along  the  lateral  aspects  of  the  abdomen,  often  being  horseshoe 
in  outline,  corresponding  to  the  course  of  the  colon. 


ACUTE    INTESTINAL    OBSTRUCTION. 


281 


Intussusception. 

The  following  are  the  most  characteristic  diagnostic  points  of  intus- 
susception, according  to  Hess,  who  has  collected  them  from  1028  cases. 


Vermiform 
Appendix 


\ Ilei 


^■«bK 


Beginning  of 
invagination  in  ileum. 

Fig.  177. — Intussusception. 
The  illustration  was  made  from  a  specimen  of  intussusception  in  an  adult,  in  which  the  clinical  picture 
was  that  of  an  appendicitis.  It  is  of  the  iliac  variety,  in  wliich  one  portion  of  the  ileum  has  been  invaginatcd  into 
the  other,  the  latter  representing  that  portion  of  the  ileum  which  is  in  close  proximity  to  the  ileocecal  valve. 
The  difference  in  color  of  the  invaginated  mucous  membrane,  which  was  deeply  congested  and  hemorrhagic, 
is  well  shown. 


Previous  History. — There  may  be  a  history  of  some  intestinal 
disturbances,  rarely  one  of  abdominal  trauma,  but  in  the  majority  of 
cases  the  first  symptoms  appear  very  suddenly. 

Abdominal  Pain. — First  symptom  without  premonition,  colicky  in 


252  THE    ABDOMEN. 

character,  uninterrupted  at  onset,  later  intermittent.  In  children  in- 
ability to  localize  it. 

Nausea  and  Vomiting. — Nausea  and  vomiting  occur  either  sim- 
ultaneously with  the  pain  or  immediately  after.  May  be  continuous 
or  occur  at  intervals. 

Evacuations  of  the  Bowels. — In  acute  cases  we  usually  have  one  or 
more  evacuations  of  fecal  matter.  After  this,  if  occlusion  is  complete, 
there  is  complete  absence  of  the  passage  of  fecal  matter  and  flatus. 
Hemorrhagic  evacuation  is  one  of  the  most  constant  symptoms  of 
invagination.  It  varies  from  a  few  streaks  to  a  profuse  hemorrhage, 
which  may  cause  death. 

Prostration. — Prostration  is  sudden  in  development  and  out  of 
proportion  to  the  other  symptoms  present. 

Tumor. — This  is  the  most  important  physical  sign  from  the  diag- 
nostic standpoint.  In  197  cases  in  which  there  is  a  complete  history, 
183  gave  the  history  of  the  presence  of  an  abdominal  tumor.  The 
presence  of  a  rectal  tumor  was  noted  in  35  cases  and  an  absence  of 
same  in  38  cases.  The  most  frequent  seat  of  the  tumor  is  the  region 
of  the  sigmoid  flexure.     The  tumor  is  relatively  very  movable. 

Meteorism.—^leteorisui  is  usually  slow  in  development  and  its 
absence  is  of  diagnostic  import.  It  depends  upon  the  degree  and  seat 
of  the  obstruction. 

Tenesmus. — Tenesmus  is  much  more  frequently  present  than  is 
meteorism.  It  is  especially  severe  in  intussusception  of  the  sigmoid 
and  rectum. 

Condition  of  the  Abdomen. — Characteristic  symptoms  or  signs, 
recognizable  on  the  abdomen  superficially,  are  usually  absent. 

Fever. — Fever  occurs  in  about  40  per  cent,  of  all  cases  of  invagina- 
tion in  which  the  symptom  is  mentioned.  Its  presence  is  to  be  expected 
when  complications  have  taken  place. 

Obstruction  from  Tumors  or  Foreign  Bodies. 
History. — An  obstruction  from  gallstones  is  to  be  suspected  in 
elderly  women,  especially  if  there  has  been  a  history  of  prior  attacks 
of  gallstone  colic.  Obstruction  from  tumors  can  only  be  suspected 
if  there  is  a  previous  history  of  gradual  loss  in  weight,  or  if  symptoms  of 
chronic  stenosis,  hke  those  referred  to  on  page  341,  have  been  present 
for  some  time  before  the  symptoms  of  complete  obstruction  occurred. 
The  symptoms  of  obstruction  from  tumors  or  foreign  bodies  appear 
rather  insidiously  in  adults,  as  compared  with  those  due  to  strangula- 


ACUTE    INTESTINAL    OBSTRLXTION.  283 

tion  or  volvulus.  There  is  but  little  pain  and  abdominal  distention  is 
much  more  gradual  in  its  onset. 

Pain  and  vomiting  are  not  marked  or  severe,  as  a  rule.  The  per- 
istalsis is  very  distinctly  visible  through  the  thin  abdominal  wall  in 
this  form  of  obstruction.     The  constipation  is  absolute,  however. 

Rectal  and  vaginal  examinations  are  of  the  greatest  value  in  adults 
in  this  form  of  obstruction  for  the  purpose  of  determining  the  presence 
or  absence  of  impacted  feces  or  the  presence  of  a  pelvic  tumor  which 
causes  compression  of  the  intestine.  In  this  form  of  obstruction  there 
may  be  apparent  relief,  consisting  in  the  passage  of  feces  and  flatus, 
and  then  recurrence  in  the  form  of  symptoms  of  absolute  obstruction. 

Adynamic  Ileus. 

A  form  of  intestinal  obstruction  due  to  acute  paralysis  of  the  mus- 
cular fibers  of  the  intestinal  coats  is  called  adynamic  ileus.  It  may 
follow  laparotomies,  injuries  of  the  spinal  cord  in  the  dorsal  region  (see 
page  668),  or  may  appear  without  any  apparent  cause.  It  is  not  due  to 
a  septic  paresis  of  the  intestine,  but  the  result  of  inhibition  of  nerve  im- 
pulses. The  diagnosis  differs  only  in  the  history  and  absence  of  ob- 
jective findings  from  the  other  forms  of  obstruction. 

Differentiation. — The  principal  conditions  from  which  acute  intes- 
tinal obstruction  must  be  differentiated  are  the  various  affections 
mentioned  under  Group  II.  It  is  often  very  difficult  to  differentiate 
acute  ileus  from  a  spreading  or  general  peritonitis,  after  the  occurrence 
of  bowel  paralysis  in  the  latter  condition,  usually  on  the  second  or  third 
day.  This  difficulty  is  due  to  the  fact  that  in  both  there  is  absolute 
constipation,  incessant  vomiting,  great  prostration,  and  rapid  pulse. 
There  is,  perhaps,  less  rigidity  and  less  pain  in  these  advanced  cases  of 
intestinal  obstruction  than  in  those  of  peritonitis.  Of  great  diagnostic 
import  -is  the  presence  of  a  history  pointing  to  an  appendicitis  or  some 
similar  condition,  and  of  like  importance  is  the  finding  of  a  strangulated 
hernia,  or  other  causes  of  intestinal  obstruction.  In  the  early  period, 
i.  e.,  in  the  first  twenty-four  to  thirty-six  hours,  the  following  difl'eren- 
tial  points  are  of  value : 

Acute  Peritonitis.  Acute   Intestinal  Obstruo 

TION. 

1.  Rigidity Uniform  and  marked.  Not  so  marked. 

2.  Abdominal  distention.  Gradual.  Rapid  except  in  intussusception. 

3.  Visible  peristalsis Not  present.  Often  visible  in  early  hours. 

4.  Pulse Gradual  increase  in  frequency.  Rapid  increase  in  frequency. 

5 .  Vomiting Present  at  first  but  does  not  recur  Incessant    from   beginning,  be- 

until  third  day.  coming  fecal. 

6.  Constipation ..Some  results  from   enemata   in    No   result   except  in   fecal   im- 

early  hours.  paction. 


284  THE   ABDOMEN, 

Other  conditions  from  which  intestinal  obstruction  must  be  differen- 
tiated are: 

Acute  Pancreatitis. — In  this  the  constipation  is  not  complete.  Vom- 
iting never  becomes  fecal.  The  rigidity  is  confined  to  the  upper  half 
of  the  abdomen  and  the  shock  and  severe  pain  in  the  epigastrium  are 
present  from  the  onset. 

Acute  Enteritis. — In  this  there  may  be  repeated  vomiting  and  pain  at 
the  umbilicus;  there  is  usually  diarrhea  present  or  it  is  possible 
to  secure  bowel  movements  by  means  of  enemata.  The  pulse  does 
not  increase  in  frequency  as  the  hours  pass,  except  when  the  diarrhea 
is  very  copious.     Abdominal  rigidity  is,  as  a  rule,  not  present. 

Perforation  of  an  Ulcer  of  the  Stomach  or  Intestine. — As  in  pancrea- 
titis, the  symptoms  of  shock  and  pain  are  more  severe  and  sudden  from 
the  beginning.  There  is  often  a  previous  history  of  ulcer  and  the 
symptoms  of  peritonitis  gradually  develop. 

Thrombosis  and  Emholism  of  Mesenteric  Artery. — The  symptoms  of 
this  condition,  when  there  is  no  blood  passed  with  the  bowel  move- 
ment, resemble  greatly  those  of  acute  obstruction,  and  it  is  impossible 
to  make  a  diagnosis  before  operation,  but  the  possibihty  of  embolism 
occurring  in  a  person  suffering  from  arteriosclerosis  must  be  borne  in 
mind.  Aside  from  this,  the  histon,'  will  throw  but  little  light  on  the 
diagnosis. 

The  symptoms  of  paralysis  of  the  gut  in  this  condition  are  so  rapid 
in  their  onset  that  it  is  impossible,  in  the  majority  of  cases,  to  distin- 
guish between  this  condition  and  obstruction  from  mechanical  or  dyna- 
mic causes. 

Finally,  it  may  be  said  that  the  diagnosis  of  intestinal  obstruction 
often  cannot  be  made  at  the  first  examination  in  the  early  hours.  But 
the  examination  should  be  repeated  from  hour  to  hour,  and  if  no 
bowxl  movement  has  occurred  or  the  enemata  are  unsuccessful,  and 
the  vomiting  continues,  accompanied  by  rise  of  pulse-rate  and  abdom- 
inal distention,  no  delay  should  be  permitted  in  performing  an  explor- 
atory' laparotomy.  Such  an  operation,  delayed  more  than  forty-eight 
hours,  during  which  the  patient  is  becoming  toxic  from  the  absorption 
of  stercoraceous  material  and  suffering  from  the  shock  of  intestinal 
obstruction,  usually  proves  fatal. 

Group  IV. — Early  Signs  of  Internal  Hemorrhage. 
RUPTURED  EXTRAUTERINE  PREGNANCY. 
There  is  often  a  history  of  a  long  period  of  sterihty,  followed  by  a 
partial  or  entire  cessation  of  menses  for  one  or  more  periods,  and  the 


ABDOMINAL    TUMORS.  285 

signs  of  pregnancy  with  expulsion  of  decidua  per  vaginam  from  time 
to  time. 

The  rupture  of  such  a  pregnancy  may  be  diagnosed  from  the  sudden 
onset  of  severe  abdominal  pain,  accompanied  by  collapse,  in  a  woman 
having  the  above  history. 

The  face  and  visible  mucous  membranes  are  very  pale,  there  is 
great  restlessness  and  thirst,  repeated  attacks  of  syncope,  and  a  rapid, 
weak  pulse.  The  abdomen  is  uniformly  rigid  and  tender,  but  not  as 
marked  as  in  a  peritoneal  infection.  Distention  gradually  increases 
and  may  become  quite  marked.  Bimanual  examination  may  reveal 
a  tender  mass  lateral  to  the  uterus  or  in  the  culdesac  of  Douglas. 


Abdominal  Tumors. 

When  we  examine  a  patient  with  an  abdominal  tumor  two  questions 
present  themselves: 

1 .  Which  viscus  is  involved  ? 

2.  What  is  the  nature  of  the  tumor? 

These  two  questions  cannot  be  answered  without  careful  consid- 
eration of  all  of  the  data  at  hand. 

These  data  are  acquired  as  follows: 

1.  A  detailed  history  is  taken. 

2.  The  great  probability  of  tumors  of  certain  viscera  occurring 
in  the  corresponding  locations. 

3.  The  results  obtained  from  an  examination  of  the  abdomen 
augmented  by  certain  tests  and  procedures  to  be  described. 

1.  History. — In  considering  the  history  one  must  not  fail  to  note 
the  age,  habits,  venereal  history,  prior  illnesses,  previous  operations, 
gain  or  loss  in  weight,  rapidity  of  enlargement  of  the  abdomen,  and 
any  other  symptoms  accompanying  the  presence  of  the  tumor.  These 
are  referred  to  again  in  connection  with  the  individual  forms  of  tumors. 

2.  Probabilities  of  Tumors  of  Certain  Viscera  Occurring  in 
Corresponding  Locations. — The  normal  location  and  other  charac- 
teristics of  each  abdominal  viscus  must  be  borne  in  mind.  This  is  of 
considerable  aid  in  making  a  diagnosis,  since  in  the  case  of  any  tumor 
we  must  first  think  whether  it  corresponds  in  location  to  some  normal 
viscus.  We  can  often  identify  certain  tumors  by  their  resemblance 
in  outline,  edge  and  consistency  to  such  a  normal  viscus.  This  is  espe- 
cially true  at  an  early  period  of  the  development  of  the  tumor. 

Many  tumors  of  the  gallbladder,  liver,  spleen,  and  kidney,  corre- 
spond in  both  their  position  and  shape  to  the  normal  organ  (Fig.  178). 


?86 


THE    ABDOMEX. 


An  overdistended  urinary  bladder  may  be  mistaken  for  an  abdominal 
tumor  unless  the  normal  location  and  shape,  when  it  is  full,  are  remem- 
bered. 

It  is  not  to  be  denied  that  certain  organs,  if  situated  in  a  part  far 
away  from  their  normal  location,  may  be  normal  in  size  or  be  markedly 
altered  and  not  be  recognized  as  belonging  to  these  viscera.     Thus 

a  normal-sized  spleen 
may  be  displaced  so  as 
to  lie  in  the  right  iliac 
fossa,  or  a  kidney  be 
located  in  the  pelvis. 

These  are  excep- 
tional cases,  and  yet  it 
is  these  ver}'  unusual 
forms  which  render 
the  diagnosis  of  ab- 
dominal tumors  a  dif- 
ficult problem  which 
in  many  cases  only 
an  explorator}'  lapa- 
rotomy solves. 

3.  The  Results 
Obtained  from  the 
Abdominal  Exam- 
ination and  its  Ad- 
juncts.— This  should 
be  undertaken  in  a 
systematic  manner  by 
the  usual  methods  of 
physical  diagnosis,  es- 
pecially inspection, 
palpation,  and  percus- 
^^"^^  sion.      The  necessity 

of  rectal,  vesical,  and 
vaginal  examination  should  never  be  forgotten.  In  addition,  it  is  neces- 
sary to  have  a  good  working  knowledge  of  all  that  chemical  and  micro- 
scopic analysis  will  reveal.  Lastly,  inflation  of  the  stomach  and  colon 
will  throw  much  light  on  the  diagnosis. 

Under  certain  conditions  examination  of  the  abdominal  cavity  is 
rendered  very  difficult.     These  conditions  are: 

I.  Rigidity  of  the  abdominal  wall.     This  is  especially  the  case  in 


Fig.  178. — Most  Frequent  Locations  or  Xarious  Tumors  of 
THE  Abdominal  Viscera. 
The  black  arrows  indicate  the  directions  in  which  they  grow: 
L,  Liver;  G,  gallbladder;  Py,  pylorus;  Pa,  pancreas;  R,  right  kidney; 
LK,  left  kidney;  Sp,  spleen;  IC,  ileocecal  tumors;  V,  tumors  due  to 
distended  bladder,  ovarian  cysts  growing  upward,  fibroids  of  uterus, 


ABDOMINAL   TUMORS.  287 

infants  and  young  children,  in  nullipara;,  in  muscular  male  adults,  or 
where  inflammatory  changes  are  present.  It  may  be  necessary  to 
give  an  anesthetic  to  overcome  this  resistance. 

2.  A  great  amount  of  fat  in  the  abdominal  wall.  This  is  one  of 
the  greatest  obstacles,  and  is  not  always  overcome,  even  though  the 
abdomen  be  relaxed  or  an  anesthetic  be  given. 

3.  The  presence  of  free  fluid  in  the  peritoneal  cavity. 


Fig.  179. — Method  of  Palpating  the  Gallbladder  or  Pylorus. 
The  patient  should  be  laid  upon  the  back  with  the  shoulders  slightly  raised  and  thighs  flexed  upon  the 
abdomen,  so  that  the  soles  of  the  feet  rest  squarely  upon  the  bed.     The  examiner  should  approach  the  patient 
from  the  right,  laying  the  hand  flat  upon  the  abdomen,  and  insert  it  gradually  deeper  while  the  patient  is  in- 
structed to  breathe,  and  thus  relax  the  abdominal  wall. 


In  such  cases  it  is  often  necessary  to  tap  the  abdomen  and  exam- 
ine the  patient  before  the  fluid  has  had  an  opportunity  to  reaccumulate. 

4.  The  presence  of  a  considerable  degree  of  tympanites. 

5.  The  presence  of  a  distended  bladder. 

In  general,  the  best  posture  for  examination  is  with  the  patient 
lying  upon  the  back,  with  the  shoulders  raised  and  thighs  flexed  upon 
the  abdomen.  Certain  special  postures  and  methods  are  described 
with  the  form  of  tumor  in  which  they  arc  of  use. 

I.  Ins  peel  ion. — This  shows  us  the  following: 

(a)  The   dilatation   of   the   superficial   veins.     This   may   indicate 


255  THE    ABDOMEN. 

obstruction  in  the  portal  circulation  if  central,  and  in  the  vena  cava 
inferior  if  lateral  (Fig.  i88). 

(b)  The  color  of  the  skin.  A  change  involving  the  color  of  the 
entire  body,  for  example,  jaundice  in  carcinoma  of  the  pancreas  (Fig. 
1 86)  or  anemia  in  malignant  conditions,  may  occur. 

(c)  Where  the  enlargement,  if  visible,  is  located,  i.  e.,  ascites  causes 
a  general  widening,  while  ovarian  cysts  enlarge  the  lower  portion  of  the 
abdomen.  Tumors  of  the  spleen  or  kidneys  enlarge  their  corresponding 
lateral  regions.  A  dilated  stomach  or  a  pancreatic  cyst  causes  a 
prominence  around  the  umbihcus. 


Fig.  i8o. — Areas  of  Dullness  and  Tympany  Respectively  m  Ascites  and  Ovarl^n  Cyst. 


II.  Palpation. — The  warm  hands  should  be  laid  flat  upon  the 
abdomen  (Fig.  179),  deeper  pressure  being  made  gradually.  For 
renal  tumors  bimanual  palpation  is  necessary  (Fig.  160).  Ballotte- 
ment  is  useful  for  deep  tumors. 

Palpation  reveals: 

(a)  The  respiratory  mobility  of  the  tumor.  Tumors  of  the  stomach, 
liver,  and  gallbladder  and  kidneys  move  up  and  dowm  with  respiration 
unless  they  are  fixed  by  adhesions.  Tumors  of  the  ovary  and  uterus 
do  not  move  with  respiration. 

(b)  The  passive  mobihty .  of  the  tumor.  Tumors  of  the  large 
intestine  and  mesentery  and  long  pedunculated  ovarian  and  uterine 


TUMORS    OF   THE    STOMACH.  289 

tumors  have  an  almost  unlimited  range  of  mobility.  The  same 
is  true  for  a  movable  spleen,  but  is  rarely  so  for  a  tumor  of  the 
pylorus,  kidney,  or  suprarenals.  Retroperitoneal  tumors  arising  from 
the  pancras  and  glands  have  but  little  passive  mobihty.  This  also 
holds  for  inflammatory  tumors  like  encapsulated  exudates  (Fig.  192). 

(c)  The  presence  or  absence  of  fluctuation. 

{d)  The  consistency,  size,  and  nature  of  the  surface  and  edges  of 
the  tumor,  and  whether  there  is  pulsation,  genuine  or  transmitted. 

III.  Percussion. — This  will  aid  in  distinguishing  ascites  from  an 
ovarian  cyst,  the  former  causing  dullness  in  the  flanks  and  tympany 
in  the  center,  and  the  latter  the  opposite  (Fig.  180). 

Percussion  will  also  help  in  distinguishing  tumors  with  fluid  or 
sohd  contents,  and  lying  close  to  the  abdominal  wall,  from  those  behind 
coils  of  intestine  or  the  stomach. 

IV.  Auscultation. — This  is  of  httle  value  except  in  the  differentiation 
of  a  pregnant  uterus  from  other  abdominal  tumors  or  in  the  diagnosis 
of  aneun^sm. 

Inflation  of  Stomach  or  Colon. — This  is  of  great  aid  in  the  diagnosis 
of  tumors  of  the  stomach,  large  intestine,  and  of  retroperitoneal  tumors 
(kidney,  pancreas,  adrenals,  lymph-nodes,  etc.). 

The  results  obtained  from  this  method  of  diagnosis  are  described 
below. 


TUMORS  OF  THE  STOMACH. 

These  are  almost  always  due  to  a  carcinoma,  rarely  to  a  sarcoma.^ 

The  only  forms  of  cancer  of  the  stomach  which  can  be  felt  through 
the  abdominal  wall  are  those  which  are  situated  at  the  pylorus  alone  or 
which  involve  the  entire  anterior  wall  as  a  massive  infiltration. 

Tumors  of  the  stomach,  especially  those  of  the  pylorus,  show  dis- 
tinct respiratory,  and  a  marked  range  of  passive  mobihty  (Fig.  181) 

If  the  stomach  is  at  a  lower  level,  as  the  result  of  a  gastroptosis  or 
of  a  dilatation,  there  is  but  little  respiratory  mobility  in  the  tumor. 
The  same  is  true  if  adhesions  exist. 

Minkowski  has  shown  that  if  one  grasps  a  gastric  tumor  during 
inspiration  and  holds  it,  the  expiratory  upward  movement  can  be 
prevented. 

Pyloric  tumors  move  to  the  right  and  downward  when  the  stomach 
is  inflated,  those  of  the  anterior  wall  move  downward,  and  both  varieties 
become  less  accessible  to  palpation  when  the  stomach  is  inflated. 

^  The  subject  of  diagnosis  of  gastric  carcinoma  is  taken  up  in  detail  on  page  335. 
19 


290 


THE    ABDOMEN. 


Tumors  of  the  stomach  are  most  frequently  felt  in  the  epigastric 
and  umbilical  regions,  but  may  be  situated  at  a  lower  level  if  a  gastrop- 
tosis  or  dilatation  (Fig.  181)  is  present.  This  can  be  elicited  by  inflation. 
One  can  often  cause  peristaltic  waves  to  pass  across  the  stomach  toward 
the  tumor,  if  dilatation  exists,  by  gently  tapping  upon  the  organ. 

Gastric  tumors  are  usually  hard  and  smooth,  but  may  be  quite  nod- 
ular. They  are  tender 
on  palpation. 

The  diagnosis  of 
whether  such  a  tumor 
is  a  gastric  carcinoma 
can  be  made  if  the 
accompanying  symp- 
toms referred  to  on 
page  335  are  present, 
and  by  excluding  the 
following  forms  of 
tumors. 

Differential 
Diagnosis. — i.  Pan- 
creatic Growths. — The 
normal  pancreas  in 
elderly  persons  with 
thin,  relaxed  abdom- 
inal walls  often  feels 
like  a  gastric  cancer. 

Neoplasms  of  the 
head  of  the  pancreas 
may  also  simulate  car- 
cinoma of  the  stom- 
ach. If  the  stomach 
and  colon  are  both  inflated,  the  pancreatic  enlargements  disappear  (Fig. 
182). 

In  pancreatic  disease  there  is  often  an  accompanying  glycosuria, 
and  stools  containing  free  fat  and  undigested  meat  particles  (see  page 
299).  There  may  also  be  ascites,  icterus,  and  hepatic  enlargement 
(Figs.  186  and  187). 

2.  Tumors  of  the  Transverse  Colon  and  Duodenum. — Those  of  the 
former,  cause  obstruction  symptoms.  They  disappear  when  the  stomach 
is  inflated,  and  become  more  prominent  when  the  colon  is  inflated.     In 


Fig.  181. — Mobility  of  Pyloric  Tumoks. 
The  dotted  circles  of  the  upper  figure  represent  the  range  of 
mobih'ty  of  some  pyloric  tumors  resulting  from  carcinoma  of  the  stom- 
ach. The  black  arrow  shows  the  direction  of  peristaltic  waves.  G, 
Location  of  stomach  and  of  pyloric  tumors  in  latter  right  iliac  region, 
in  cases  of  gastroptosis,  or  of  extreme  dilatation  of  the  stomach. 


TUMORS    OF   THE    LIVER. 


291 


addition,  there  is  an  absence  of  pathologic  change  in  the  gastric  contents 
analysis. 

Tumors  of  the  duodenum  cannot  be  distinguished  from  those  of 
the  stomach,  but  while  hydrochloric  acid  is  absent  in  the  vomitus  of  the 
latter,  it  is  usually  present  in  the  vomitus  of  tumors  of  the  duodenum. 

3.  Carcinoma  of  the  Gallbladder. — Icterus  is  usually  present.  There 
is  no  lateral  mobility  and  no  respiratory  fixation  as  described  above. 
There  are  rarely  any 

dyspeptic  disturb- 
ances or  signs  of  a 
dilated  stomach.  A 
history  of  previous 
gallstone  attacks  is 
usual. 

4.  Tumors  0}  the 
Left  Lobe  of  the  I^iver. 
— These  become  very 
prominent  beneath  the 
abdominal  wall  when 
the  stomach  is  inflated 
(see  page  297). 

5.  P erigastritic 
Thickening  Around  an 
Old  Ulcer  of  the  Stom- 
ach.— The  induration 
may  be  so  marked  as 
to  simulate  a  carcin- 
oma. The  course  of 
the  case  is  much 
slower,  there  is  a  his- 
tory of  ulcer,  and  the 
stomach  contents  will 
show  hyperchlorhydria. 
compared  with  carcinoma,  which  is  most  frequent  in  the  aged. 


Fig.  182. — Location  of  Pancreatic  Cysts  Before  and  After 
Inflation  of  Colon  and  Stomach. 
V,  Stomach  before  inflation;  TC,  location  of  transverse  colon 
before  inflation.  The  black  oval  area  represents  the  pancreatic  tumor, 
which  may  be  quite  prominent  before  inflation  of  the  stomach  and 
colon,  but  disappears  when  the  latter  procedure  is  used.  The  white 
dotted  lines,  IV  and  IC,  represent  the  locations  of  the  inflated  stomach 
and  colon  respectively,  overlapping  the  pancreatic  tumor. 


It   usually  occurs  in  younger  individuals,  as 


TUMORS  OF  THE  LIVER. 

I.  Corset  Liver. 

Through  the  pressure  of  a  corset,  a  lobule  of  the  liver  may  become 

almost   completely  separated   from  the   remainder  of  the  organ   and 

simulate  other  tumors  of  the  upper  abdomen.     It  occurs  most  frequently 


292 


THE    ABDOMEN. 


in  the  right  lobe.  A  deep  groove  or  furrow  divides  the  hver  proper 
from  the  supemumerar}^  lobe  which  contains,  instead  of  liver  tissue,  only 
blood-vessels  and  bile-ducts.  The  majority  of  these  tumors  cause  no 
symptoms,  but  they  become  so  far  separated  as  to  seem  hke  a  neoplasm 
having  no  connection  with  the  liver.     It  may  drag  the  gallbladder 

with  it,  just  as  does 
an  elongated  Riedei 
lobe  (Fig.  162).  As 
a  result  of  this, 
the  gallbladder  may 
be  found  at  the  level 
of  the  umbilicus  or 
even  lower. 

If  the  tumor  is 
freely  movable,  or 
if  the  bridge  con- 
necting it  with  the 
liver  is  very  thin, 
there  may  be  great 
difficulty  in  diag- 
nosis. The  same 
is    true    for    those 


cases  in  which  a 
coil  of  intestine  lies 
between  it  and  the 
liver. 

The  diagnosis, 
in  those  cases  in 
which  the  groove 
between  the  acces- 
sory lobe  and  the 
liver  is  not  deep,  is 
easy,  if  one  can  feel 
this  transverse  de- 
pression and  observe  that  the  tumor  moves  with  the  liver  during 
respiration. 

Differential   Diagnosis. — Floating  Kidney. — This   can  be  better 
felt  from  the  lumbar  region,  while  the  corset  lobe  is  most  distinct  an- 
teriorly.  If  the  colon  is  inflated,  it  Hes  in  front  of  the  kidney  (Fig.  191). 
A  movable  kidney  can  be  replaced  upward  and  backward  toward 
its  noi-mal  position,  and,  on  the  other  hand,  can  be  pushed  further 


Fig.  183.— Front  View  op  a  Case  of  General  Enteroptosis  (R.  C. 
Coffey). 
L,  Liver  outline  on  surface,  sho-n-ing  marked  descent;  S,  stomach;  note 
the  fact  that  the  lesser  curvature  lies  at  the  level  of  the  umbilicus,  and  the 
greater  curvature  midway  between  the  umbilicus  and  symphysis;  K,  right 
and  left  kidneys,  showing  marked  do\vnward  displacement;  T,  transverse 
colon,  also  markedly  prolapsed. 


TUMORS    OF    THE    LIVER. 


293 


dovm  than  the  corset  liver.  If  the  patient  is  laid  upon  the  left  side, 
one  can  separate  the  sharp  lower  edge  of  the  liver  from  that  of  the  kidney, 
which  is  more  rounded  or  blunt.  If  enteroptosis  exists,  the  diagnosis 
may  become  very  difficult,  since  movable  kidney  may  be  present  at 
the  same  time. 

Renal  Tumors. — These  often  have  the  shape  of  the  normal  kidney 
and  he  behind  the  inflated  colon.  The  dullness  over  the  renal  tumor 
is  not  continuous  with  that 

of  the  hver,  as  in  a  corset  lobe,  ^        ''  v'^l/"'>o 

but  tympany  due  to  the  over- 
lying intestines  exists.  The 
lower  edge  of  the  renal  tumor 
is  not  as  sharp  and  lacks  the 
notches  often  present  in  a 
corset  lobe. 


II.  Floating    Liver    (Hepat- 

OPTOSIS). 

A  liver  which  has  de- 
scended in  the  abdominal 
cavity  may  simulate  a  tumor 
of  the  right  side.  It  may  sink 
to  the  pelvis.  It  can  usually 
be  replaced  into  its  normal 
position.  On  palpation,  one 
can  usually  distinguish  the 
sharp  lower  edge  and  the 
notch  between  the  right  and 
left  lobes  (Fig.  183).  It  is  ten 
times  as  frequent  in  women 
as  in  men,  especially  in  those 
with  flabby,  relaxed  abdom- 
inal walls.  The  consistency 
of  the  tumor  is  that  of  the 

normal  liver.  The  normal  hver  dullness  is  replaced  by  tympany,  but 
reappears  when  the  organ  is  put  into  its  normal  position.  It  may  cause 
at  times  attacks  of  pain  like  biliary  colic,  radiating  to  the  right  shoulder. 
-Usually  it  causes  a  feeling  of  fullness  in  the  abdomen  and  digestive  dis- 
turbances. The  diagnosis  may  be  very  difficult  if  ascites  coexists.  It 
would  be  necessary  to  perform  paracentesis  first. 

Differential  Diagnosis. — Floating  or  Movable  Kidney. — The  hepa- 


FiG.  184. — Sagittal  Section  in  Median  Line  of  a  Case 
OF  General  Enteroptosis  (R.  C.  Cofifey). 
D,  Under  surface  of  diaphragm;  the  blank  space  be- 
tween D  and  L  (liver)  is  the  space  formerly  occupied  by  the 
liver  before  its  descent;  S,  prolapsed  stomach;  T,  prolapsed 
transverse  colon;  I,  prolapsed  coil  of  ileum;  note  elongation 
of  the  mesentery  as  the  result  of  the  prolapse. 


294  THE    ABDOMEN. 

tic  tumor  is  larger,  more  superficial,  has  the  characteristic  sharp  lower 
edge,  is  notched,  and  there  is  an  absence  of  normal  hver  dullness 
until  the  tumor  is  replaced. 

The  renal  tumor  has  the  outline  of  the  normal  kidney  and  lies 
behind  the  colon,  when  this  is  inflated  (Fig.  191). 

Tumors  of  the  Liver  Itself. — In  carcinoma  the  surface  is  irregular 
and  often  umbilicated,  and  the  liver,  if  enlarged  much  downward,  also 
extends  upward  to  its  normal  level  at  the  sixth  rib.  The  same  is  true 
for  hydatid  cysts. 

Tumors  and  Cysts  of  the  Omentum. — These,  though  movable,  cannot 
be  replaced  to  the  same  extent  from  above  do\\mward  as  a  floating  Hver, 
and  are  separated  by  tympany  (intestines)  from  the  dullness  of  the 
normally  placed  liver. 

III.  EcHiNococcus  Cysts  of  the  Liver. 

This  condition  usually  occurs  in  a  unilocular  form  and  is  most 
often  in  the  right  lobe,  causing  a  localized  bulging  on  the  surface  and 
giving  rise  to  a  marked  tumor.  The  liver  is  enlarged,  and  if  the  cyst 
is  near  the  upper  surface,  it  pushes  the  diaphragm  upward.  The 
normal  liver  dullness  is  increased  upward  in  a  circumscribed  manner, 
as  in  a  pleural  effusion,  but  differs  from  it  by  having  respiratory 
movement. 

When  the  cyst  lies  near  the  lower  border  of  the  right  lobe  it  causes 
a  tumor,  resembling  a  distended  gallbladder  or  renal  enlargement. 
When  the  cyst  protrudes  from  the  anterior  surface  of  either  the  right 
or  left  lobe,  it  causes  a  marked  locahzed  bulging.  These  latter  forms 
rarely  give  a  sense  of  fluctuation,  and  the  pecuhar  hydatid  thrill,  so 
pathognomonic  when  found,  is  an  inconstant  sign.  The  presence  of 
echinococcus  can  be  suspected  from  the  presence  of  a  locahzed  tumor 
with  absence  of  constitutional  signs,  such  as  fever,  unless,  as  rarely 
occurs,  suppuration  has  taken  place. 

The  diagnosis  can  be  positively  made  only  if  the  characteristic 
scohces  or  booklets  are  found  in  the  clear,  watery  contents.  Explor- 
atory puncture  is  dangerous  and  should  be  replaced  by  a  laparotomy 
for  diagnostic  purposes.  An  .T-ray  is  of  great  aid  in  confirming  a  diag- 
nosis of  echinococcus  if  calcification  has  occurred. 

Differential  Diagnosis. — i.  Echinococcus  cysts  of  the  anterior 
surface  must  be  differentiated  from  the  following: 

(a)  Cystic  Disease  of  the  Liver. — The  elevations  are  usually  small 
and  multiple.  If  large,  they  can  be  differentiated  from  echinococcus 
cysts  by  exploration  only. 


TUMORS    OF   THE   LIVER.  295 

(b)  Carcinoma. — Here  there  is  cachexia,  umbihcation  of  the  tumors 
(Fig.  185),  and  the  tumors  are  harder  and  muhiple. 

(c)  Abscess  of  the  Liver. — If  no  fever  is  present  the  differentiation 
may  be  very  difficuh,  but  in  abscess  the  tumor  is  not  so  hard  or  tense. 
Usually,  however,  fever  and  other  septic  symptoms  are  present  in  hepa- 
tic abscess,  and  there  is  a  history  of  dysentery  to  be  obtained.  If  a  hy- 
datid cyst  suppurates  the  diagnosis  from  primary  liver  abscess  is 
almost  impossible  before  operation. 

2.  When  the  hydatid  cyst  projects  from  the  lower  border. 

(a)  From  a  Dilated  Gallbladder. — This  tumor  of  the  gallbladder  is 
pear-shaped,  it  can  only  be  separated  from  the  edge  of  the  liver  with 
difficulty  and  is  also  more  movable  than  an  echinococcus  cyst. 

(b)  Permanent  or  Intermittent  Hydronephrosis. — In  the  intermittent 
form  there  is  a  history  of  alternating  disappearance  and  presence  of  the 
tumor,  the  former  associated  with  polyuria.  A  permanent  hydronephrosis 
will  have  more  or  less  the  form  of  the  normal  kidney,  project  more  in 
the  lumbar  region,  and  lie  behind  the  inflated  colon  (Fig.  191).  If 
the  patient  is  laid  upon  the  left  side  the  echinococcus  cyst  is  less 
prominent. 

3.  When  the  echinococcus  cyst  is  on  the  upper  border  of  the  liver. 
{a)  From  Pleuritic  Effusion. — The  diagnosis  can  only  be  made  by 

finding  the  booklets  in  the  fluid  removed  by  exploratory  puncture.  An 
upper  border  of  dullness,  not  unlike  that  found  in  subphrenic  abscess, 
occurs  in  the  case  of  an  echinococcus  cyst  of  the  upper  surface  of  the 
liver;  i.  g.,  the  upper  border  is  convex  upward  either  in  front  or  behind 
(Fig.  163),  while  in  pleural  effusion  it  is  almost  horizontal  (Fig.  140). 
(Jb)  From  Hydatids  of  the  Lung  and  Pleura. — A  differentiation  is 
almost  impossible  if  situated  on  the  right  side.  Hemoptysis  and 
cough  are  more  frequent  in  hydatids  of  the  lung. 

(c)  From  Subphrenic  Abscess. — Here  the  history  of  a  primary  cause 
of  suppuration,  e.  g.,  in  the  appendix,  and  the  presence  of  fever,  etc., 
are  of  aid.  If  the  abscess  contains  gas  there  is  tympany  instead  of 
dullness,  and  the  .v-ray  will  not  show  a  shadow,  as  in  hydatid.  Ex- 
ploration will  reveal  the  absence  of  booklets  and  the  presence  of  pus. 

IV.  Cystic  Disease  of  the  Liver. 
This  condition,  resembling  congenital  cystic  disease  of  the  kidneys 
(Fig.  192),  is  often  present  with  the  latter  condition,  and  should  be 
suspected  if  the  liver  and  both  kidneys  are  enlarged  in  a  patient  having 
uremic  symptoms.  The  surface  of  the  liver  is  nodular  and  some  of 
the  many  cysts  may  be  large  enough  to  simulate  hydatids.     In  such  a 


296  THE    ABDOMEN. 

case  a  differentiation  is  impossible  without  a  microscopic  examination 
of  the  wall  of  the  cyst  and  its  contents. 

V.  Syphilis  of  the  Liver. 
There  are  three  forms  of  syphilis  which  are  of  interest  from  a  sur- 
gical standpoint. 

1.  Cases  of  large  gummata  resembling  neoplasms. 

2.  Cases  of  division  of  the  right  or  left  lobes  or  both  into  multiple 
lobules  as  the  result  of  cicatrization  following  gummatous  infiltration. 

3.  Cases  with  irregular  fever  and  gumma  formation  resembling 
hepatic  suppuration. 

4.  Cases  resembling  gallstones. 

The  first  point  in  the  case  of  gummatous  enlargements  is  to  identify 
the  tumor  as  belonging  to  the  liver,  then  to  ascertain  the  presence  of 
syphilis  elsewhere  or  a  previous  history  of  the  disease,  and  finally  to 
observe  the  disappearance  of  the  tumor  under  antisyphilitic  treatment. 
If  a  gumma  softens  and  fever  is  present,  one  cannot  differentiate  it 
from  a  hepatic  abscess,  in  the  absence  of  a  syphilitic  history. 

The.  chief  condition  from  which  a  lobulated  luetic  liver  must  be 
distinguished  is  floating  kidney.  The  latter  has  a  much  greater  range 
of  mobility,  has  the  form  of  the  normal  kidney,  and  can  be  best  felt  by 
bimanual  palpation  (Fig.  160).  Inflation  of  the  colon  shows  the  tumor 
to  lie  behind  the  distended  large  intestine. 

Rarely  obstructive  jaundice,  with  attacks  of  bihary  colic,  may  follow 
the  pressure  of  a  gumma,  or  the  traction  of  syphilitic  cicatrices  on  the 
portal  fissure  (Rolleston,  Bilhngs). 

VI.  Malignant  Neoplasms  of  the  Liver. 

Sarcoma  and  carcinoma  both  occur  as  primary  and  secondary 
growths  in  the  liver.  The  primary  are  quite  rare  and  cannot  be  distin- 
guished clinically  from  the  secondary  forms.  The  stomach  (Fig.  204), 
colon,  gallbladder,  and  breast  (Fig.  152)  are  the  most  frequent  seats 
of  the  primary  growths,  in  cases  having  secondary  cancer  of  the  Hver. 
Sarcomata  are  most  often  secondary  to  primary  melanosarcomata  of 
the  uveal  tract  and  of  the  skin. 

The  diagnosis  of  malignant  disease  may  be  made  from  the  onset  of 
cachexia,  the  rapid  enlargement  of  the  liver,  and  the  palpal^le,  hard, 
umbilicated  tumors  (Fig.  185)  of  the  li\-cr  edge.  In  a  patient  who  has 
a  primary  growth  elsewhere,  the  diagnosis  is  positive;  but  in  one  in 
whom  no  such  focus  can  be  found,  the  diagnosis  is  a  very  probable  one. 

At  times,  especially  in  the  case  of  primary  sarcomata,  one  lobe  may 


Fig.  185. — Metastatic  Carcinoma  of  the  Liver  Secondary  to  the  Primary  Carci- 
noma OF  THE  Stomach  Shown  in  Fig.  204. 
Note  the  umbilicated  centers  of  each  nodule.     This  illustration  assists  in  forming  a 
conception  of  the  innumerable  metastases  from  a  comparatively  insignificant  primary 
carcinoma. 


TUMORS    OF   THE    GALLBLADDER.  297 

be  enormously  enlarged  and  its  surface  smooth  and  firm.  From  their 
location,  such  tumors  can  be  diagnosed  as  being  hepatic  in  origin,  and 
inflation  of  the  stomach  will  render  them  more  prominent. 

In  addition  to  the  above  symptoms,  there  are  marked  jaundice  (even 
cholemia  with  hemorrhages  into  the  skin  and  from  the  mucous  mem- 
branes), ascites,  evidences  of  metastases  in  the  peritoneum,  and  often 
febrile  manifestations. 

Differential  Diagnosis. — i.  Cirrhosis  of  the  Liver. — The  nodula- 
tion  of  the  surface  is  never  as  marked  and  umbilicated  as  in  carcinoma. 
If  ascites  is  present,  as  is  the  case  in  both  affections,  the  fluid  should  be 
removed  before  palpating  the  liver.  The  jaundice  is  not  as  deep  in 
cirrhosis.  Rapid  enlargement  of  the  liver  and  marked  cachexia  speak 
for  malignancy.  A  search  for  a  primary  focus  of  cancer  or  sarcoma 
should  always  be  made.  The  spleen  is  usually  enlarged  in  cirrhosis, 
but  is  rarely  so  in  malignant  disease. 

2.  Syphilis. — Gummata  are  usually  not  as  hard  as  carcinomatous 
nodules,  there  is  a  history  of  syphilis,  and  the  constitutional  disturbance 
is  shght.     The  course  is  much  more  chronic. 


TUMORS  OF  THE  GALLBLADDER. 

The  two  chief  affections  which  might  be  mistaken  for  other  abdom- 
inal tumors  are  hydrops  and  primary  malignant  disease  of  the  gall- 
bladder. 

Hydrops. — Distention  of  the  gallbladder  occurs  as  the  result  of 
blocking  of  the  cystic  duct,  followed  by  the  accumulation  of  secretions, 
and  the  formation  of  a  tumor  which  varies  greatly  in  size.  It  may  be 
quite  movable  or  fixed  by  adhesions.  There  are  three  degrees  of  dis- 
tention: 

(a)  Those  in  which  the  tumor  is  of  relatively  small  size. 

(b)  Cystic  tumors  of  great  size  extending  to  the  left  of  the  median 
line. 

(c)  Cystic  tumors  filling  the  greater  part  of  the  right  side  of  the 
abdomen  (Fig.  162). 

The  diagnosis  in  the  lirst  class  may  be  made  from  the  fact  that  there 
are  but  few  subjective  symptoms,  although  a  history  of  one  or  more 
attacks  of  bihary  coHc  is  often  obtainable.  Its  outline  can  often  be 
seen  through  a  thin  abdominal  wall.  It  can  be  felt  to  be  attached  to 
the  liver  above,  is  in  close  contact  with  the  anterior  abdominal  wall, 
and  has  a  wide  range  of  mobility. 

Palpation   and   percussion   are   often   very   unsatisfactory,   for  the 


298  THE    ABDOMEN. 

reasons  that  unless  adherent  the  tumor  is  so  movable  that  it  cannot  be 
readily  grasped,  and,  again,  instead  of  dullness  there  is  tympany  from 
the  underlying  intestines.  If  the  abdominal  wall  is  quite  relaxed, 
its  lower  rounded  border  may  be  distinctly  felt  as  a  tense  elastic  body, 
especially  if  one  hand  be  placed  posteriorly  and  the  other  in  front,  as 
in  palpating  the  kidney  (Fig.  160}. 

Inflation  of  the  stomach  makes  the  tumor  more  prominent  and 
pushes  it  to  the  right,  while  inflation  of  the  colon  pushes  it  upward,  un- 
less, as  rarely  occurs,  the  colon  is  adherent  between  the  tumor  and  the 
abdominal  wall.     Exploratory  puncture  is  dangerous. 

The  larger  forms  of  cystic  tumors  of  the  gallbladder  which  fill  the 
greater  part  of  the  right  half  of  the  abdomen  are  infrequent,  and  can 
be  recognized  from  the  history,  from  their  great  mobility,  smooth  sur- 
face, their  pyriform  or  cucumber  shape  (i\.lban-Doran),  and  the  fact 
that  they  have  their  pedicle  at  the  liver,  instead  of  in  the  pehis  as 
ovarian  cysts  do.  If  adhesions  exist  there  may  be  great  difficulty  in 
diagnosis.  There  is  often  distinct  fluctuation  in  these  large  gall- 
bladder retention-cysts. 

Differential  Diagnosis. — i.  Floating  Kidney. — This  always  re- 
tains the  characteristic  outhne  of  the  kidney.  It  can  be  replaced  toward 
the  renal  region.  Inflation  of  the  colon  causes  it  to  disappear  while 
the  gallbladder  tumor  is  pushed  upward. 

2.  Groiiihs  in  the  Stomach  and  Intestines. — These  can  be  distin- 
guished by  the  difference  in  the  symptoms  and  by  the  results  of 
inflation  of  the  colon  and  stomach. 

3.  Echinococcus  Cysts  or  Malignant  Tumors  Projecting  from  the 
Lower  Edge  of  the  Liver. — These  are  much  more  irregular  in  outhne, 
harder,  and  not  movable  except  with  respiration. 

4.  Distention  of  the  Gallbladder  Following  Cancers  of  the  Pancreas. — 
In  this,  it  may  distend  to  a  quite  marked  size,  but  there  are  an  accom- 
panying cachexia,  ascites,  and  deep  jaundice  (Fig.  186).  Explora- 
tory incision  shows  the  head  of  the  pancreas  infiltrated  and  enlarged. 


Malignant  Disease  of  the  Gallbladder. 
This  frequently  follows  cholelithiasis,  and  should  be  suspected  if 
a  hard  mass  is  found  in  the  right  hypochondriac  region  following  a 
history  of  gallstones  in  an  elderly  patient  with  persistent  jaundice.  The 
tumor  is  usually  nodulated,  rarely  smooth,  and  is  very  hard  in  consis- 
tency. This  induration,  the  nodular  surface,  and  the  rapid  appearance 
of  cachexia  followed  by  icterus  and  ascites,  serve  to  distinguish  it  from 


PANCREATIC   TUMORS.  299 

cholelithiasis;  but  in  the  latter  the  organ  may  be  indurated  so  that  a 
diagnosis  is  often  not  made  until  the  abdomen  is  opened.  The  pains 
in  cancer  are  not  sharp  and  colicky,  but  of  a  dull  character.  If  fever 
and  colicky  pains  appear,  they  indicate  an  infection  of  the  carcinoma- 
tous gallbladder.     The  course  is  a  very  chronic  one. 


PANCREATIC  TUMORS. 

Inflammatory  tumors  in  the  epigastric  and  umbihcal  regions  due  to 
peripancreatic  suppuration  following  an  attack  of  acute  pancreatitis 
were  referred  to  on  page  270. 

Other  tumors  due  to  pancreatic  disease  may  be  divided  into  three 
classes. 

(a)  Those  due  to  chronic  pancreatitis. 

(b)  Cysts. 

(c)  Neoplasms. 

Chronic  Pancreatitis. 

Although  the  majority  of  these  cases  can  be  recognized  only  at  opera- 
tion or  autopsy,  it  is  important  to  know  that  marked  induration  can 
follow  chronic  pancreatitis.  At  times  it  is  possible  to  recognize  the 
tumor  through  the  intact  abdominal  wall  during  life,  and  in  one  case 
of  the  author's  such  a  tumor  was  mistaken  for  a  carcinoma  of  the 
head  of  the  pancreas.  The  diagnosis  of  chronic  pancreatitis  can 
rarely  be  made.  Even  when  the  abdominal  cavity  is  opened,  as  in 
the  case  just  mentioned,  the  induration  is  difficult  to  distinguish  from 
that  of  carcinoma,  and  the  diagnosis  can  only  be  made  from  the  sub- 
sequent clinical  course.  The  tumor  is  palpable  and  is  located  in  the 
epigastrium  to  the  right  of  the  middle  line.  In  the  cases  observed 
by  Riedel  and  in  my  own  case  the  tumor  had  so  great  a  range  of  respi- 
ratory and  passive  mobihty  as  to  be  mistaken  for  a  gallbladder  full  of 
calculi.  If,  in  addition  to  such  a  rarely  palpable  induration,  jaundice, 
fatty  stool,  glycosuria,  and  emaciation  are  present,  chronic  pancreatitis 
can  be  diagnosed.  There  is  often  a  history  of  bihary  colic,  of  gastro- 
duodenal  catarrh,  or  of  gastric  duodenal  ulcer. 

Differential  Diagnosis. — i.  GaUslones  in  the  Common  Duct. — 
In  this  condition  there  is  the  history  of  frequent  attacks  of  biliary 
colic  at  first  without  jaundice,  chills  and  fever,  but  later  accompanied 
by  these  symptoms.  The  absence  of  tumors  speaks  also  for  gall- 
stones in  the  common  duct. 

2.  Cancer  of  Head  of  Pancreas. — The  jaundice  is  deep  and  constant. 


300 


THE    ABDOMEN. 


the  liver  and  gallbladder  are  greatly  enlarged,  and  ascites  is  present. 
Emaciation  is  also  more  rapid.  In  some  cases  only  exploratory  incision 
will  aid  in  making  a  diagnosis.  As  mentioned  above,  palpation  of  the 
tumor  will,  at  times,  give  misleading  information,  since  the  induration 
in   choronic   pancreatitis   may  be  as   great   as   in   carcinoma.     More 


Fig.  iS6. — Front  View  of  Case  of  Carcinoma  of  the  Head  of  the  Pancreas. 
The  area  of  liver  dullness  is  outlined  in  black.  R,  Right  lobe  of  liver;  L,  left  lobe  of  Kver.  The  notch 
between  the  two  lobes  could  be  distinctly  palpated  to  the  left  of  the  median  Hne  at  the  level  of  the  umbihcus. 
G,  Enormously  distended  gallbladder  easily  palpable  through  the  abdominal  wall.  Enormous  size  of  the  liver 
was  due  to  passive  hyperemia  and  to  secondary  deposits  in  the  liver  parenchyma.  The  yellowish  color  of  the 
skin  was  due  to  pressure  on  the  common  duct. 


rehance  is  to  be  placed  on  the  presence  of  deep  icterus  and  ascites, 
which  speak  for  mahgnancy. 

7,.  Gallstones  in  the  Gallbladder. — There  is  tenderness  over  the 
gallbladder,  (Figs.  167  and  173)  and  the  history  of  attacks  of  biliary 
coHc.  The  tumor  is  seldom  as  hard  as  that  of  a  chronic  indurative 
pancreatitis  and  does  not  disappear  when  the  stomach  and  colon  are 
inflated,  as  the  pancreatic  induration  does. 


PANCREATIC    TUMORS. 


301 


Pancreatic  Cysts. 

These  cause  a  bulging  in  the  median  hne  of  the  epigastric  region 
(Fig.  182)  or  between  the  middle  hne  and  left  costal  arch.  In  sixteen 
cases  Koerte  found  the  tumor  below  the  navel,  and  in  eleven  cases 
Koerte  and  Neumann/  his  assistant,  have  observed  right-sided  pan- 
creatic cysts  lying  near  the  kidney  (Fig.  191)  and  simulating  renal 
tumors. 

There  is  an  area  of  dullness  over  the  tumor.  The  epigastric  bulging 
is  smooth,  tense  and  rounded,  and  may  vary  in  size  from  time  to  time. 


Fig.  187. — Side  View  of  Case  of  Carcinoma  of  the  Head  of  the  Pancreas. 
Yellow  tint  of  flesh  due  to  obstruction  of  common  duct,  as  it  passes  through  head  of  pancreas  to  reach  the 
duodenum.  G,  Enormously  distended  gallbladder  which  could  be  distinctly  felt  through  the  abdominal  wall. 
Its  contents  were  cystic  on  account  of  the  long-standing  obstruction  of  the  common  duct.  R,  Lower  border  of 
right  lobe  of  liver,  which  is  enormously  enlarged  oa  account  of  secondary  deposits.  The  upper  level  of  liver 
dullness  is  shown  just  below  the  level  of  the  nipple.  A,  Area  of  dullness  due  to  free  fluid  in  peritoneal  cavity 
due  to  pressure  upon  portal  vein. 


Such  tumors  have  no  respiratory  or  passive  mobihty,  and  inflation 
of  the  stomach  and  colon  causes  them  to  disappear,  the  former  lying 
above  and  the  latter  below  it  (Fig.  182),  unless  one  of  the  following 
rare  positions  of  the  cyst  occurs: 

(a)  The  cyst  lies  above  the  stomach  and  pushes  the  latter  downward. 

(b)  It  may  be  behind  the  transverse  colon. 

(c)  It  may  lie  below  the  transverse  colon. 

(d)  It  may  lie  behind  the  ascending  colon  (Fig.  191). 
In  these  positions  the  cyst  is  often  quite  mobile. 


'  "Deutsche  Zeitschrift  f.  Chirurs 


Bd.  l.x.xiv. 


302  THE    ABDOMEN. 

The  diagnosis  may  be  made  from  the  above  special  characteristics 
of  the  tumor,  from  the  mode  of  onset,  the  accompanying  symptoms, 
and  the  analysis  of  its  contents  when  obtained  at  operation. 

The  modes  of  onset  are  chiefiy  three: 

1.  Gradual. — With  loss  of  weight,  symptoms  of  indigestion,  and 
cohcky  pains  like  those  of  gallstones. 

2.  Sudden. — After  blows  on  the  upper  abdomen. 

3.  No  preceding  trauma  or  symptoms  mentioned  under  i. 

After  the  cyst  begins  to  develop  the  patient  may  either  have  severe 
pain  and  vomiting  or  show  no  symptoms  other  than  the  gradually 
increasing  distention  of  the  abdomen.  Jaundice,  hematemesis,  and 
diarrhea  are  occasionally  present.  In  the  urine  sugar  is  often  found; 
in  the  feces,  an  excess  of  fat  and  undigested  meat  may  be  found.  The 
fluid  should  never  be  obtained  for  analysis  by  exploratory  puncture, 
but  only  during  a  laparotomy.  The  most  important  diagnostic  feature 
is  that  the  fluid  in  a  pancreatic  cyst  digests  fibrin  and  albumin. 

Differential  Diagnosis. — Echinococcus  Cysts  of  the  Liver. — The 
tumor  in  these  is  continuous  with  the  hepatic  dullness,  while  in  pancreatic 
cysts  there  is  an  area  of  resonance  between  the  tumor  and  the  liver, 
which  is  increased  when  the  stomach  is  inflated.  When  the  pancre- 
atic cyst  lies  above  the  stomach  these  signs  are  of  no  value,  but  this 
form_  of  pancreatic  cyst  is  much  more  movable  than  is  an  echinococcus 
cyst. 

Retention-cysts  of  the  Gallbladder. — -These  were  discussed  on  page 
297.  The  chief  points  are  their  greater  mobility  and  the  continuation 
of  dullness  from  the  liver  to  the  tumor. 

Renal  Cystic  Tumors. — If,  as  shown  in  Fig.  191,  the  tumor  lies 
behind  the  colon,  a  differentiation  is  impossible,  and  even  after  opera- 
tion the  fluid  may  fail  to  show  any  characteristic  ferments  in  such  cases. 
In  general,  however,  renal  tumors  are  accompanied  by  colicky  pains  along 
the  ureter,  by  urinary  changes,  and  give  rise  to  more  bulging  of  the  ileo- 
costal  space.  In  the  most  frequent  location  of  pancreatic  cysts  (Fig. 
182)  the  colon  when  inflated  lies  below  the  tumor  and  not  in  front  of  it. 

Ovarian  Cysts. — When  these  have  a  long  pedicle  they  may  simu- 
late a  pancreatic  cyst.  The  presence  of  both  ovaries  in  the  pelvis  will 
exclude  ovarian  tumor. 

Bimanual  pelvic  examination  in  the  Trendelenburg  position  will 
show  that  the  tumor  has  no  relation  to  the  ovaries.  The  history  will 
show  that  the  tumor  first  appeared  in  the  epigastrium.  Upon  inflation 
of  the  colon,  the  ovarian  lies  below  and  the  pancreatic  cyst  above  it, 
except  in  those  rare  cases  where  these  latter  he  below  the  colon. 


PANCREATIC    TUMORS.  303 

Mesenteric  Cysts.— The  history  is  of  great  value.  Appearance  of 
the  tumor  after  an  injury  or  following  colicky  pains  speaks  for  a  pan- 
creatic cyst,  as  do  fatty  stools,  glycosuria,  undigested  meat  fibers  in  the 
feces,  and  emaciation.  The  mesenteric  cyst  is  more  movable,  lies 
below  the  umbilicus,  and  when  the  large  bowel  is  inflated  the  transverse 
colon  lies  across  the  tumor.  Only  when  a  pancreatic  cyst  has  developed 
between  the  layers  of  the  transverse  mesocolon  is  differentiation  im- 
possible. 

Neoplasms  of  the  Pancreas. 
Primary  carcinoma  of  the  head  of  the  pancreas  is  the  most  frequent 
form  of  new-growth.      The  diagnosis  may  be  made  from  the  follow- 
ing symptoms : 

1.  Severe  pain  in  the  epigastrium,  radiating  through  to  the  back. 
It  is  either  continuous  (a  dull  ache)  or  intermittent  (agonizing). 

2.  Jaundice.     This  is  present  except  in  cancer  of  the  body  or  tail. 

3.  Distention  of  the  gallbladder  and  enlargement  of  the  Hver  (Fig. 
186). 

4.  Ascites. 

5.  Early  cachexia. 

6.  A  palpable  tumor  in  the  epigastrium  which  becomes  less  notice- 
able when  the  stomach  is  inflated. 

7.  Free  fat  and  undigested  meat  fibers  in  large  quantities  in  the  feces. 

8.  Albuminuria — rarely  glycosuria. 

Differential  Diagnosis. — i.  Gallstones  in  the  Common  Duct. — The 
jaundice  is  more  sudden  in  its  appearance  and  often  accompanied  by 
irregular  chills  and  fever.  There  is  often  a  history  of  frequent  previous 
attacks  of  biliary  coHc  without  jaundice  and  the  gallbladder  itself  is 
tender  to  the  touch.  On  inflating  the  stomach  and  colon  the  tumor 
will  not'  disappear,  as  pancreatic  tumors  do.  Ascites  and  cachexia 
speak  for  malignant  disease  of  the  pancreas. 

2.  Chronic  Pancreatitis. — In  the  absence  of  ascites  and  jaundice, 
it  is  impossible  to  differentiate  this  from  carcinoma  "except  by  the  fact 
that  in  the  latter  there  is  early  and  much  more  marked  cachexia.  The 
induration  in  chronic  pancreatitis  often  feels  as  hard  at  operation  as 
in  cancer  of  the  head  of  the  pancreas.  In  the  latter,  however,  the  con- 
dition becomes  progressively  worse,  while  in  chronic  pancreatitis  it 
-improves  as  soon  as  stones  in  the  common  duct  arc  removed. 

3.  Carcinoma  0}  the  Pylorus. — The  tumor  is  much  more  mobile 
than  in  cancer  of  the  pancreas,  there  is  a  predominance  of  gastric 
symptoms  with   evidences  of  dilatation,   and   changes   in  the  gastric 


304 


THE    ABDOMEN. 


juice.  A  cancer  of  the  pylorus  will  not  be  accompanied  by  jaundice, 
ascites,  and  changes  in  the  stool,  and  the  tumor  will  move  to  the  right 
when  the  stomach  is  inflated  instead  of  becoming  concealed,  as  does  one 
of  the  pancreas. 

4.  Carcinoma  of  the  Colon. — This  may  be  accompanied  by  ascites, 
but  there  are  no  changes  in  the  stools,  or  jaundice,  as  in  cancer  of  the 
pancreas.     The  tumor  is  more  movable  than  that  of  the  pancreas  and 

does  not  disappear 
when  the  colon  is  in- 
flated. There  are  of- 
ten distinct  stenosis 
symptoms. 


TUMORS  OF  THE 
SPLEEN. 

The  normal  spleen 

cannot    be     palpated 

except  in  very  thin  and 

relaxed    patients   and 

then  only  indistinctly. 

The  conditions  which 

most  often  give  rise  to 

splenic  tumors  are: 

1.  Floating  spleen. 

2.  Splenic  enlarge- 
ments due  to  leukemia, 
pseudoleukemia,  ma- 
laria, or  acute  splen- 
itis. 

3.  Neoplasms,  in- 
cluding echinococcus 
cysts. 

Floating  or  Wandering  Spleen. — This  condition  is  frequently 
present  as  a  part  of  a  general  enteroptosis  (Fig.  183),  or  is  often  asso- 
ciated with  left-sided  floating  kidney.  A  tumor  may  be  found  which 
has  caused  practically  no  symptoms  except  a  slight  dragging  sensation. 
Quite  rarely  the  tumor  may  give  rise  to  acute  symptoms,  such  as  pain, 
vomiting,  muscular  rigidity,  and  tenderness,  due  to  strangulation  or 
twisting  of  its  pedicle. 

A  wandering  spleen  is  most  often   found  in  the  left  iliac  region, 


Fig.  1S8. — Enlargement  of  Abdomen  as  the  Result  of  a  Leu- 
kemic Hypertrophy  of  the  Spleen. 
The  dark  color  of  the  skin  of  the  abdomen  is  due  to  the  repeated  ap- 
pUcation  of  the  .r-ray. 


TUMORS    OF   THE    SPLEEN. 


305 


resting  in  the  iliac  fossa.  Less  often  lias  it  been  found  in  the  right 
iliac  fossa  and  pelvis.  In  the  latter  situation  it  may  cause  obstruc- 
tion. 

A  diagnosis  is  made  by  the  palpation  of  the  characteristic  notches 
(Fig.  189)  along' its  anterior  border,  its  smooth  surface,  and  the  absence 
of  the  spleen  in  its  normal  place.  It  can  be  distinguished  from  floating 
kidney  by  the  fact  that  the  latter  can  be  replaced  to  the  renal  while  the 
spleen  disappears  behind 
the  costal  arch  unless 
held  by  adhesion.  A 
floating  kidney  lies  be- 
hind the  colon,  has  the 
outhne  and  rounded 
lower  pole  of  the  normal 
kidney,  and  in  addition 
is  much  less  movable 
than  a  floating  spleen. 

Enlargements  of 
the  Spleen. — These  are 
described  at  length  in 
text-books  of  medicine. 
The  writer  has  seen  a 
number  of  cases  in  which 
such  spleens,  enlarged  as 
the  result  of  general  dis- 
eases, such  as  leukemia 
(Fig.  188),  pernicious 
anemia,  pseudoleuke- 
mia, chronic  malaria,  and 
syphiHs,  have  been  mis- 
taken for  neoplasms  of 
the  spleen. 

In  every  case  of 
splenic  enlargement  of 
long  standing  one  must 

remember  the  above  causes  and  examine  the  blood  or  search  for  a  cause 
elsewhere  than  in  the  spleen. 

Another  cause  of  enlarged  spleen  is  that  found  in  si)lcnomcgaly  or 
Banti's  disease,  which  may  or  may  not  be  associated  with  anemia. 
For  full  descriptions  of  the  various  forms  of  this  disease  the  reader  is 
referred  to  the  various  treatises  on  internal  medicine. 


Fig.  189. — Anterior  View  of  the  Case  of  SARroiiA  of  the 
Spleen  Shown  in  Fig.  190. 
The  outlines  of  the  spleen  have  been  marked  with  a  dotted 
line.  Observe  the  notches  on  the  right  margin  of  the  tumor, 
characteristic  of  splenic  tumors.  E,  Ensiform  process  in  costal 
arch.     Observe  the  formation  of  a  well-marked  caput  medusae. 


3o6  THE    ABDOilEX. 

There  are  certain  physical  signs  by  which  all  of  these  enlargements 
may  be  recognized  as  splenic,  viz.  : 

1 .  They  retain  the  general  outhne  of  the  spleen. 

2.  They  have  its  notched  anterior  border. 

3.  They  he  in  front  of  the  inflated  colon  and  not  behind  it,  as  do 
renal  tumors. 

4.  They  have  respiratory  mobility. 

(a)  Echinococcus  of  the  Spleen. — This  is  very  rare  and  causes  an 
enlargement  of  the  spleen  which  can  seldom  be  diagnosed  before  opera- 


r 

w 

^" 

V 

/     ' 

i 

1 

/         ' 

^^^ ' 

/     ; 

^^P 

/      / 

""x 

\L 

/ 

/          ;' 

,; 

■j 

jk 

'\^ 

c/ 

/u 

.   .-rcvi 

p 

1 

6.           * 

' 

Fig.  190. — Lateral  View  or  Abdoiten  of  Same  Patiext  as  Sho\^"nin  Fig.  1S9,  with  S.\rcoma  of  the 

Spleen. 
L,  Lower  palpable  border  of  tumor;    U,  upper  border  of  tumor  as  outlined  by  percussion;    C,  costal  arch. 

tion.     Occasionally  fluctuation  may  be  felt  and  the  tumor  recognized 
as  one  of  the  spleen. 

Sarcoma  of  the  Spleen. — Both  primary  sarcoma  and  carcinoma 
of  the  spleen  occur,  but  of  the  two,  the  former  is  the  more  frequent. 
The  tumor  occupies  the  left  half  of  the  abdomen,  extending  do\^Tlward 
from  beneath  the  left  costal  arch  (Fig.  189).  It  lies  quite  superficially, 
has  a  nodulated,  hard  surface,  and  often  retains  the  characteristic  notches 
of  the  anterior  border  of  the  spleen  (Fig.  189).  Its  rapidity  of  growth, 
its  hardness,  and  the  accompanying  cachexia  are  diagnostic  of  the 
malignant  character  of  the  tumor.  It  lies  in  front  of  the  inflated  colon 
and  does  not  give  rise  to  hematuria,  as  does  a  mahgnant  renal  tumor. 
It  also  causes  early  peritoneal  metastases  which  can  be  felt  as  separate 
tumors. 


TUMORS    OF   THE    INTESTINES.  307 

TUMORS   OF   THE   INTESTINES. 
There  are  three  places  in  the  abdominal  cavity  where  tumors  which 
have  their  origin  in  the  small  and  large  intestine  may  be  felt.     These 
are,  in  the  order  of  their  frequency: 

1.  Rectum. 

2.  Sigmoid  flexure. 

3.  Cecum  and  ascending  colon. 

The  rarer  seats  of  a  tumor  are  the  appendix,  duodenum,  ileum,  and 
jejunum. 

Unfortunately  for  the  purposes  of  diagnosis,  a  palpable  tumor  is  a 
rather  late  sign  of  malignant  disease  of  the  intestine,  so  that  it  should 
be  made  from  the  other  signs  and  methods  referred  to  on  page  308. 
Those  of  the  rectum  are  discussed  on  page  359.  At  this  point  the  diag- 
nostic points  of  intestinal  tumors  -per  se  will  be  discussed  whether  due 
to  neoplasms  or  inflammator}-  conditions. 

I.  Inflammatory  Tumors. — These  are  the  result  of  one  of  two 
affections,  viz. :  tuberculosis  and  actinomycosis.  They  are  almost 
always  found  in  the  cecum.  Quite  rarely  tumor-like  inflammatory 
masses  appear  around  the  sigmoid  as  the  result  of  perforation  of  the 
appendices  epiploic^. 

(a)  Ileocecal  Tuberculosis. — In  this  a  vertical,  sausage-shaped,  hard 
tumor  is  found  in  the  right  iliac  region  w^hose  tuberculous  nature  is 
often  not  suspected.  The  diagnosis  frequently  made  before  operation 
is  that  of  a  carcinoma.  The  tumor  is  quite  fixed  and  more  sensitive 
to  pressure  than  a  carcinoma,  and  is  not  quite  as  hard.  There  are  also 
periodic  attacks  of  severe  pains,  as  the  result  of  an  enterostenosis,  and 
alternating  diarrhea  and  constipation  is  a  quite  common  symptom. 
Rarely  symptoms  of  acute  intestinal  obstruction  arise.  The  disease 
occurs,  as  a  rule,  at  an  earlier  age  than  carcinoma;  there  is  often  fever 
and  it  is  not  accompanied  by  as  much  emaciation  as  is  the  malignant 
process.  The  finding  of  blood  in  small  quantities  is  more  characteristic 
of  carcinoma  than  of  tuberculosis. 

(b)  Ileocecal  Actinomycosis  .-—This  localization  of  the  ray-fungus 
gives  rise  to  a  tumor-like  mass  greatly  resembling  that  of  ileocecal 
tuberculosis.  The  mass  is,  however,  more  commonly  attached  to  the 
abdominal  wall,  which  is  indurated.  In  the  absence  of  a  history  of  a 
focus  of  actinomycosis  elsewhere  it  is  impossible  to  make  a  diagnosis 
until  sinuses  have  formed,  in  the  pus  of  which  the  characteristic  ray- 
fungus  is  found.  The  tumor  is  as  fixed,  but  not  as  tender  as  in  tuber- 
culosis.    It  is  not  as  hard  nor  does  the  general  nutrition  suft'er  as  much 


306  THE    ABDOMEN. 

as  in  carcinoma.  The  latter  usually  appears  at  a  more  advanced  age 
(above  forty),  although  there  are  exceptions  to  this.  The  condition  is 
usually  accompanied  by  some  fever.  The  administration  of  potassium 
iodid  or  of  copper  sulphate,  as  recently  recommended  by  Bevan,^  may 
aid  in  making  a  differential  diagnosis,  since  these  cause  an  improvement 
if  the  tumor  is  the  result  of  an  actinomycotic  infection. 

2.  Neoplasms  of  the  Intestines. — Benign  tumors  are  relatively 
rare  and  can  seldom  be  diagnosed  before  operation.  They  give  rise, 
if  large,  to  symptoms  of  chronic  stenosis  and  may  cause  intussusception. 
Of  the  mahgnaht  growths,  sarcoma  occurs  in  about  6  per  cent,  of  the 
cases,  the  remainder  being  due  to  carcinoma. 

The  most  frequent  locations,  according  to  recent  statistics  of  Tuttle,^ 
in  2432  cases,  exclusive  of  the  stomach,  are  as  follows: 

Rectum 1690  cases. 

CecTim  and  ascending  colon 283 

Sigmoid 182 

Transverse  and  descending  colon 160 

Appendix 60 

Ileum,  jejunum,  and  duodenum 69 

The  clinical  picture  varies  according  to  the  seat  of  the  growth,  but  is 
generally  that  of  a  stenosis  of  the  bowel. 

Cancer  of  the  Duodenum. — The  symptoms  are  so  closely  alhed 
to  those  of  a  pyloric  cancer  as  to  be  indistinguishable,  even  when  a 
tumor  is  palpable,  which  is  usually  not  the  case  until  late  in  the  disease. 

Cancer  of  the  Remaining  Small  and  Large  Intestine  except 
Rectum. — The  diagnosis  of  cancer  anywhere  between  the  duodenum  and 
rectum  is  usually  to  be  made  from  a  combination  of  certain  general  and 
local  symptoms.  The  general  signs  are  a  gradually  increasing  anemia 
and  cachexia  for  which  no  other  cause  can  be  found.  These,  when  asso- 
ciated with  intestinal  disturbances  in  a  person  above  forty,  should 
always  lead  to  the  suspicion  of  a  mahgnant  growth.  On  the  other 
hand,  there  are  cases  in  which  the  general  and  local  symptoms  are  so 
latent  that  a  suspicion  of  malignancy  is  not  aroused  until  a  tumor  which 
has  all  the  physical  characters  of  an  intestinal  one,  is  found  during  an 
abdominal  or  pelvic  examination.  Quite  rarely  cases  of  carcinoma  of 
the  intestine  have  an  acute  onset  accompanied  by  fever,  and  a  diagnosis 
is  made  only  at  operation,  for  what  was  thought  to  be  an  acute  inflam- 
matorv  condition.     The  chief  local  diagnostic  points  are: 

I.  Symptoms  of  Stenosis. — These   are  increased   visible   peristalsis 

^  "Journal  American  ISIed.  Association,"  Nov.  11,  1905. 
"  "^ledical  Record,"  Xov.  4,  1905. 


TUMORS    OF    THE    INTESTINES.  309 

and  severe,  griping,  colicky  pains,  often  referred  to  a  particular  spot 
and  relieved  as  soon  as  flatus  has  been  passed  per  rectum.  Often, 
however,  the  patient  does  not  pass  any  gas  after  these  cohcky  pains, 
and  this  is  quite  characteristic  of  stenosis. 

2.  Condi tioji  of  the  Bowel  Movements. — Obstinate  constipation  is 
present  in  the  majority  of  the  cases.  This  condition  often  alternates 
with  diarrhea,  which  may  be  a  prominent  early  symptom,  especially 
when  accompanied  by  the  frequent  but  unsuccessful  desire  to  go  to 
stool.  The  nearer  the  cancer  is  to  the  rectum,  the  more  marked  is  this 
tenesmus.  The  feces  may  be  ribbondike  if  the  stenosis  is  low  down. 
The  appearance  of  pus,  blood,  and  mucus  in  the  stools  is  of  great  value 
if  a  dysentery  can  be  excluded. 

3.  Tumor. — The  chief  characteristic  of  intestinal  tumors  is  their 
great  mobihty.  This  is  especially  true  of  those  of  the  small  intestine, 
sigmoid,  and  transverse  colon,  less  so  of  those  of  the  cecum  or  of  the 
hepatic  and  splenic  flexures.  The  latter  can  often  be  best  felt  by 
gradually  pushing  the  hand  under  the  costal  arches. 

The  tumors  are  very  hard  and  nodular.  They  may  appear  to  be 
larger  at  one  examination  than  at  another,  owing  to  the  fact  that. feces 
collect  on  the  proximal  side,  from  time  to  time.  The  hardening  of  the 
tumor  caused  by  the  contraction  of  the  hypertrophied  musculature  on 
the  proximal  side  of  the  stenosis,  followed  by  a  gurgling  sound  due  to 
passage  of  gas  through  the  stenosis,  may  often  be  felt  and  heard. 

Ascites  may  be  an  early  symptom,  accompanying  a  tumor  of  the 
colon. 

Differential  Diagnosis. — -The  conditions  from  which  cancer  of  the 
small  and  large  intestine  must  be  differentiated  depend  upon  their 
respective  locations.     They  are  as  follows : 

Those  of  duodenum  and  transverse  colon Cancer  of  pylorus,  of  head  of  the  pancreas. 

Tumors  of  omentum  and  mesentery. 
Those  of  hepatic  flexure Cancer  of  gallbladder. 

Tumors  of  liver. 

Tumors  of  right  kidney. 
Those  of  splenic  flexure Tumors  of  spleen. 

Tumors  of  left  kidney. 
Those  of  cecum  and  appendix Actinomycosis  and  tuberculosis  of  cecum. 

Post-appendiceal  induration. 

Those  of  sigmoid  flexure Tumors  of  ovary  and  uterus. 

Those  of  jejunum  and  ileum Xon-malignant  strictures. 

Those  of  all  parts  of  colon From  fecal  impaction  and  gallstones. 


3IO  THE   ABDOMEN. 

TUMORS  OF  THE  PERITONEUM  AND  MESENTERY. 

Tumors  of  the  Mesentery. — Cystic  Tumors. — Cysts  constitute 
the  majority  of  mesenteric  tumors;  the  proportion  of  soHd  to  cystic 
tumors  being  as  i  to  4. 

The  smaller  cysts  have  a  wide  range  of  passive  mobihty  and  rarely 
cause  any  symptoms.  The  larger  ones  cause  a  bulging  in  the  umbihcal 
region  and  are  not  as  freely  movable.  These  larger  ones  push  the 
intestines  aside  and  cause  symptoms  of  stenosis,  and  in  some  cases  even 
complete  obstruction.  They  may  give  the  sense  of  fluctuation.  These 
cysts  may  be  of  dermoid,  hydatid,  serous,  bloody,  or  chylous  nature, 
and  are  often  adherent  to  the  neighboring  viscera. 

Both  the  smaller  and  larger  varieties  of  mesenteric  tumors  may  be 
suspected  from  the  presence  of  a  tumor  in  the  umbilical  region,  from 
the  fact  that  they  are  not  adherent  to  the  abdominal  wall  hke  omental 
tumors,  and,  lastly,  their  extreme  mobihty,  except  when  very  large. 

They  must  be  differentiated  from  the  following: 

Tumors  of  the  omentum These  are  usually  adherent  to  the  anterior 

abdominal  wall. 

Pancreatic  cysts. These  show  some  disturbance  in  the  pan- 
creatic secretion  and  lie  behind  the  in- 
flated stomach  and  colon. 

Retroperitoneal  cysts These  are  immovable  and  lie  behind  the  in- 
flated colon. 

Ovarian  cysts By  elevating  the  pelvis,one  can  feel  the  pedicle 

of  these  tumors  connected  with  the  uterus. 

Movable  kidney  and  hydronephrosis These  retain  the  outline  of  the  kidney,  lie 

more  laterally,  and  behind  the  colon. 

Encapsulated  tuberculous  peritonitis This  may  greatly  resemble  a  mesenteric  cyst 

as  shown  in  Figs.  195,  196,  but  when  the 
patient  lies  down  the  enlargement  tends 
to  become  flatter,  while  the  cysts  retain 
their  convex  surface. 

Tumors  of  the  Omentum  and  Peritoneum. — These,  as  in  the  case 
of  the  mesentery,  are  either  cystic  or  solid.  Both  become  adherent  quite 
early  to  the  abdominal  wall.  Echinoccocus  cysts  constitute  the  most 
frequent  variety  of  cystic  tumors,  while  carcinoma  occurs  most  often 
in  the  form  of  a  solid  tumor.  '  Carcinoma  may  occur  both  as  a  primary 
and  secondary  growth.  The  latter  follows  cancer  of  the  stomach  and 
intestine.  The  diagnosis  may  be  readily  made  if  there  is  a  history  of 
a  primary  growth;  but  if  there  is  none,  it  must  be  made  from  the  presence 
of  certain  symptoms. 

Lipomata  are  the  most   frequent    form.     They  do  not  fluctuate, 


TUMORS    OF   THE    KIDNEY.  3II 

although  they  may  yield  a  sense  of  pseudo-fluctuation.  They  grow 
quite  rapidly  and  cause  early  stenosis  symptoms. 

If  the  omentum  is  chiefly  involved,  a  transverse,  very  hard  tumor 
is  to  be  felt  at  or  above  the  umbiHcus.  It  is  adherent  to  the  anterior 
abdominal  wall  and  accompanied  by  ascites  and  progressive  emaciation. 
Multiple  hard  tumors  are  to  be  felt,  if  the  parietal  peritoneum  is  also 
involved,  and  these  are  accompanied  by  ascites. 

The  transverse  tumor  may  occur  both  in  tuberculous  and  simple 
prohferative  peritonitis.  These,  however,  occur  at  a  younger  age 
than  does  carcinoma  and  emaciation  is  not  nearly  as  marked.  The 
nature  of  the  fluid  in  cancer  is  usually  hemorrhagic,  but  this  may  also 
be  the  case  in  tuberculous  peritonitis. 


TUMORS  OF  THE  KIDNEY. 

The  best  method  of  examination  of  tumors  of  the  kidney  is  by 
palpation  of  the  abdomen,  with  the  patient  in  a  recumbent  position, 
the  knees  flexed  and  shoulders  elevated  (Fig.  i6o),  one  hand  placed 
over  the  corresponding  renal  region,  while  the  other  presses  the  abdom- 
inal wall  in  gradually  but  firmly,  using  the  entire  palmar  surface  of  the 
hand  and  not  the  finger-tips  alone. 

Another  method  which  is  not  as  frequently  used  is  that  recommended 
by  Israel,  which  consists  in  having  the  patient  lie  upon  the  healthy 
side  while  the  renal  region  is  palpated  bimanually  on  the  diseased  side. 
In  patients  who  are  not  too  stout,  and  whose  abdominal  walls  are 
relaxed,  the  lower  pole  of  the  kidney  may  be  normally  felt  a  little  above 
the  level  of  the  umbihcus  at  the  external  border  of  the  rectus  abdominahs. 

Abdominal  tumors  which  are  due  to  abnormal  conditions  of  the 
kidney  may  be  divided  into  four  classes: 

1.  Congenital  displacements  and  malformations  of  the  kidney. 

2.  Movable  kidney. 

3.  Diseases  which  are  accompanied  by  enlargement  of  the  kidney, 
such  as  hydronephrosis,  pyonephrosis,  pyelonephritis,  tuberculosis, 
nephrolithiasis,  and  neoplasms. 

4.  Tumors  which  are  due  to  neoplasms  of  the  kidney. 

I.  Congenital  Displacements  and  Malformations  of  the  Kidney. 
(a)  It  is  practically  impossible  to  diagnose  a  congenital  displacement 
of  the  kidney  before  operation.     Such  kidneys  do  not  give  rise  to  symp- 
toms unless  enlarged  through  inflammation,  and  their  presence  in  such 
abnormal  places  as  the  pelvis  is  seldom  suspected.     I  have  seen  two 


312  THE    ABDOMEN. 

such  cases.  In  one  of  these  the  kidney  was  located  over  the  promontory 
of  the  sacrum,  and  caused  some  pain,  the  etiology  of  which  was  not 
clear  until  the  kidney  was  discovered  at  operation.  In  the  second  case 
the  congenitally  displaced  kidney  was  found  incarcerated  between 
the  pregnant  uterus  and  the  rectum  and  was  the  cause  of  the  severe 
dystocia.  One  may  suspect  that  an  abdominal  tumor  is  a  congenitally 
displaced  kidney  if  ureteral  catheterization  is  performed  and  it  is  found 
impossible  to  catheterize  the  ureter  upon  the  side  of  the  suspected 
kidney  tumor.  Such  obstruction  may  be  due  to  other  causes,  such  as 
Stricture  of  the  ureter,  etc.,  and  the  diagnostic  value  of  ureteral 
catheterization  is  therefore  not  great. 

(b)  Congenital  malformations  of  the  kidney,  such  as  horseshoe 
kidney,  cannot  be  diagnosed  before  operation,  unless  some  change 
such  as  a  hydronephrosis  supervenes,  when  it  may  cause  a  tumor 
lying  transversely  at  the  middle  of  the  pathologically  situated  kidneys, 
which  can  be  diminished  by  compression  and  which  is  found  to  be 
retroperitoneal. 

2.  Movable  or  Floating  Kidney. 

Eighty-five  per  cent,  of  movable  kidneys  occur  in  women.  The 
diagnosis  may  be  made  from  the  presence  of  a  movable  tumor  ha\dng 
the  typical  form  of  the  kidney,  with  convex  outer  and  concave  inner 
borders,  and  the  round,  blunt,  lower  pole.  This  tumor,  hke  all  renal 
tumors,  usually  lies  behind  the  inflated  colon.  It  can  be  readily  brought 
to  the  anterior  abdominal  wah  and  then  can  be  replaced  toward  the  renal 
region.  An  interesting  point  is  that  such  abnormal  mobility  is  often 
associated  with  a  general  enteroptosis. 

In  addition  to  the  tumor  itself,  the  cases  may  be  divided  chnically 
into  three  classes : 

(a)  Those  in  which  the  tumor  is  not  accompanied  by  any  symptoms 
referable  to  the  kidney. 

(b)  Those  in  which  the  symptoms  are  those  of  a  drawing  pain 
in  the  lower  abdomen  and  lumbar  region,  which  may  become  colicky 
and  radiate  do\ATi  the  ureter,  accompanied  by  evidences  of  nervous 
dyspepsia  and  constipation.  The  pain  decreases  when  the  patient 
lies  down. 

(c)  Those  cases  which,  in  addition  to  the  tumor,  give  the  history 
of  recurrent  attacks  which  have  been  termed  "Dictl's  crises,"  and 
described  on  page  271.  Such  an  attack  is  characterized  by  severe  pain, 
chin,  nausea  and  vomiting.  The  pain  radiates  along  the  ureter.  There 
is  but  little  urine  passed  during  the  attack,  but  following  it  there  is 


TUMORS    OF   THE    KIDNEY,  313 

polyuria.  During  the  attack  itself  the  kidney  may  be  greatly  enlarged 
and  tender,  but  this  disappears  with  the  acute  syndrome.  The  urine 
contains  red  blood-cells  in  moderate  quantity  after  the  attack,  and  not 
during  it,  as  occur  in  renal  colic. 

Differential  Diagnosis. — (a)  Movable  kidney  must  be  differen- 
tiated from  a  corset  liver.  This  is  very  difficult  if  they  are  both  present 
on  the  right  side.  Diagnosis  is  aided  by  laying  the  patient  on  the  opposite 
side,  as  recommended  by  Israel,  when  one  can  separate  the  lower  edge 
of  the  liver,  which  is  always  more  or  less  sharp,  from  the  kidney. 

{h)  From  the  cystic  tumors  of  the  liver  and  enlarged  gallbladder. 
These  have  a  distinct  respiratory  mobility,  and  are  much  nearer  the 
surface  than  a  kidney.  They  cannot  be  replaced  into  the  renal  region 
hke  a  tfoating  kidney,  and  the  tumor  itself  is  continuous  with  the  hver, 
while  in  the  case  of  the  kidney,  especially  when  the  colon  is  inflated, 
there  is  an  area  of  tympany  between  the  tumor  and  the  kidney. 

(c)  Tumors  of  the  Colon  and  Stomach. — Here  the  history  of  the  case 
will  show,  either  the  symptoms  of  a  pyloric  stenosis  or  an  enterostenosis, 
and  there  will  be  more  or  less  emaciation.  The  inflation  of  the  colon 
or  of  the  stomach  will  show  more  accurately  the  relation  of  the  tumor 
to  these  structures,  and  in  the  case  of  the  pyloric  tumor,  examination 
of  the  stomach  contents  will  throw  additional  Hght. 

(d)  Pedunculated  Ovarian  and  Uterine  Tumors. — Their  connection 
with  the  uterus  through  the  ovarian  ligament  can  be  determined  by 
bimanual  examination;  the  floating  kidney  shows  the  characteristic 
form  and  can  be  readily  replaced. 

3.  Diseases  which  are  Accompanied  by  Enlargement  of  the  Kidney. 
Pyonephrosis  and  pyelonephritis  have  been  discussed  on  page  252. 
Tuberculosis  and  nephrolithiasis  are  taken  up  on  page  363. 

Hydronephrosis, — This  causes  a  tumor  which  is  either  constantly 
prominent,  or  is  intermittent  in  its  presence.  This  latter  form  is  most 
often  accompanied  by  floating  kidney,  recognition  of  which  enables  the 
diagnosis  of  the  condition.  The  hydronephrotic  enlargement  of  the 
kidney,  like  all  renal  tumors,  appears  from  beneath  the  costal  arch  in 
the  lateral  aspects  of  the  abdomen.  Bilateral  palpation  enables  the  tumor 
to  be  brought  either  nearer  to  the  abdominal  wall  or  to  become  more 
prominent  posteriorly  in  the  space  between  the  last  rib  and  the  crest  of 
the  ilium.  If  the  hydronephrosis  is  a  recent  one,  the  tumor  itself  is  firm. 
If  it  is  of  longer  duration,  distinct  fluctuation  may  be  found.  The 
tumor  lies  behind  the  inflated  colon,  has  a  marked  degree  of  mobihty, 
and  its  surface  is  uniformlv  smooth. 


314 


THE    ABDOMEN, 


The  differential  diagnosis  of  this  form  of  renal  enlargement  has  been 
discussed  under  the  subjects:  echinococcus  of  the  liver;  cystic  enlarge- 
ment of  the  gallbladder;  cysts  of  the  pancreas;  ovarian  tumors;  tumors 
of  the  spleen,  and  neoplasms  of  the  kidney,  from  all  of  which  it  must 
be  differentiated.     In  renal  tumors  it  may  be  said,  in  general,  that  they 

lie  behind  the  colon, 
and  this  assists  in  the 
diagnosis. 

RENAL  NEOPLASMS. 

Neoplasms  of  the 
kidney  which  may  be 
recognized  clinically 
are  of  two  varieties : 

1.  Polycystic  kid- 
neys (Fig.  192). 

2,  Mahgnant  tu- 
mors. 

I.  Polycystic      Kid- 
neys. 

The  diagnosis  may 
be  made  from  the  as- 
sociation of  one  or 
more  of  the  following 
symptoms  and  physi- 
cal findings. 

(a)  The  presence 
of  bilateral  tumors 
with  nodulated  sur- 
faces, having  all  of  the 
characteristics  of  renal 
tumors  as  given  on 
page  315.  Quite  rarely  a  tumor  is  only  to  be  felt  on  one  side.  A  palp- 
able tumor  is  present  in  25  per  cent,  of  all  cases. 

(h)  The  symptoms  of  a  chronic  interstitial  nephritis,  viz.,  high- 
tension  pulse,  cardiac  hypertrophy,  large  quantities  of  urine  with  low 
specific  gravity  containing  a  trace  of  albumin  and  few  casts.  Rarely 
uremic  coma  occurs. 

Differential  Diagnosis. — These  cases  can  be  differentiated  from 
chronic  interstitial  nephritis  with  attacks  of  hematuria  by  the  fact  that  the 
hematuria  in  nephritis  is  never  as  severe  as  in  polycystic  disease,  and 


Fig.  191. — Relatioxs  of  Renal  Tumor   of   Right  Side   to  In- 
flated Colon. 
I,  Renal  tumor;   2,  transverse  colon;  the  inflated  ascending  colon 
lies  in  front  of  the  tumor.     A  similar  retroperitoneal  condition  may  be 
due  to  unusual  position  of  a  pancreatic  cyst  simulating  a  renal  tumor. 


TUMORS    OF    THE    KIDXEY.  315 

the  further  fact  in  that  in  the  latter  bilateral,  palpable  tumors  are  present 
in  25  per  cent,  of  the  cases. 

From  hydronepJirosis  it  can  be  distinguished  by  the  unilateral  occur- 
rence, the  smooth  surface  and  greater  regularity  of  a  hydronephrotic 
tumor. 
2.  Malignant  Tumors. 

The  diagnosis  of  a  malignant  neoplasm  of  the  kidney  may  be  made 
from  a  consideration  in  each  case  of  five  factors  which  vary  greatly  in 
value  and  in  frequency. 

These  are: 

1.  Hematuria. 

2.  Pain. 

3.  Tumor. 

4.  Cachexia. 

5.  Metastases. 

I.  Hematuria  occurs  in  about  70  per  cent,  of  all  cases  as  the  first 


Fig.  192. — External  View  of  Coxgexital  Cystic  Kidney.     (See  text.) 

symptom.  The  hemorrhage  occurs  spontaneously,  independent  of  exer- 
cise, may  be  quite  large  in  amount  and  last  for  months.  Quite  often 
casts  of  the  ureter,  in  the  form  of  worm-like  clots,  are  found  in  the  urine. 

The  hematuria  of  renal  calculus  is  increased  or  caused  by  exercise, 
is  never  as  great  in  amount  as  in  tumor,  does  not  last  as  long,  and  is 
usually  accompanied  by  cohc. 

In  tuberculosis  the  hematuria  is  small  in  amount,  not  influenced  by 
exercise,  and  accompanied  by  pus  and  tubercle  bacilli  in  the  urine. 

The  hematuria  of  polycystic  kidney  is  rarely  as  profuse  as  that  of 
malignant  tumor  and  does  not  last  as  long  and  is  accompanied  by  the 
signs  of  high  vascular  tension  and  polyuria. 


3i6 


THE    ABDOMEX. 


Hematuria  in  chronic  nephritis  is  rarely  as  marked;  there  are 
never  worm-Hke  clots,  and  one  finds,  in  addition,  the  cardiovascular 
changes  characteristic  of  this  disease. 

It  is  impossible  to  distinguish  the  hematuria  known  as  essential  or 

idiopathic  from  that  due  to  mal- 
ignancy unless  tumor  or  cachexia 
is  present.  This  form  of  hemat- 
uria, however,  runs  a  more  chronic 
course. 

2.  Pain.  This  is  very  rarely 
the  first  symptom.  When  present, 
it  is  of  a  dull,  dragging  character, 
referred  to  the  lumbar  regions  and 
radiating  to  the  thigh.  During  an 
attack  of  hematuria  the  passage  of 
the  worm-Hke  clots  causes  typical 
renal  colic  in  the  case  of  renal 
tumors. 

3.  Tumors.  The  majority  of 
cases  in  adults  are  hypemephro- 
mata  or  sarcomata,  while  in  chil- 
dren the  latter  form  predomin- 
ates. The  physical  characteristics 
of  such  renal  tumors  may  be  sum- 
med up  as  follows : 

(a)  The  colon  when  inflated, 
lies  in  front  of,  or  on  the  inner  side 
of  the  renal  tumor.  The  latter 
may  be  pushed  so  far  inward  by  a 
large  mass  that  there  is  no  tym- 
pany over  the  tumor  when  the 
colon  is  inflated  (Fig.  191). 

{h)  The  tumor  can  best  be  pal- 
pated  by   the  bimanual  method 
shown  in  Fig.  160.     By  alternately 
raising  the  posterior  and  depres- 
sing the  anterior  hand  during  expiration,  the  size,  consistency,  and  char- 
racter  of  the  surface  may  be  ascertained.     A  second  method  is  to  lay 
the  patient  on  the  heahhy  side  and  then  palpate  bimanually. 

{c)  The  general  outlines  of  the  kidney  may  be  retained.    These  are  the 


Fig.  193. — ^Anterior  View  of  a  Case  of  Sarcoma 

OF  THE  Kidney  in  a  Boy  of  Fi\-e. 
K,   Outline  of   kidney;    L,  outline  of   greatly  en- 
larged liver. 


TUMORS    OF   THE    KIDNEY.  317 

concave  inner  and  convex  outer  borders,  and  the  blunt,  rounded,  lower 
pole. 

When  the  tumor  is  quite  localized  in  the  lower  pole,  or  very  large, 
the  resemblance  to  the  normal  shape  is  absent. 

{d)  Renal  tumors  cause  a  fullness  in  the  space  between  the  last 
rib  and  the  crest  of  the  ihum  (ihocostal  space).  They  lie  nearer  the 
anterior  abdominal  wall  than  does  the  normal  kidney. 

{e)  The  tumor  may  be  so  large  as  to  occupy  almost  the  entire  ab- 
dominal cavity,  as  in  the  case  shown  in  Figs.  193  and  194,  so  that  it  is 
impossible  to  determine  from  which  organ  the  tumor  has  its  origin. 

(/)  Benign  tumors,  with  the  exception  of  single  and  multilocular 
cysts,  seldom  give  rise  to  palpable  tumors.  MaHgnant  tumors  cause  an 
irregular  round  mass  with  a  nodular  surface  and  rapid  growth.     If 


IS.. 


Fig.  194. — Side  View  of  Same  Child  Shown  in  Fig.  193  (Sarcoma  of  the  Kidney). 
K,  Outline  of  kidney  on  the  abdominal  wall;  L,  left  edge  of  enlarged  liver. 


retrograde  changes  or  softening  are  marked,  the  tumor  may  feel  like  a 
cystic  one. 

{g)  Renal  tumors  when  small  have  a  moderate  range  of  passive  but 
practically  no  respiratory  mobility. 

4.  Cachexia.  This  is  usually  not  marked  until  the  tumor  attains 
a  large  size  (Fig.  193).  Emaciation  is  more  rapid  and  marked  in  children 
(Fig.  193)  than  in  adults.  One  must  distinguish  the  marked  anemia 
resulting  from  hematuria  from  a  cachectic  condition.  Occasionally  a 
renal  tumor  is  accompanied  by  quite  marked  elevations  of  tem- 
perature. 

5.  Metastases.  There  are  no  symptoms  which  are  characteristic 
of  the  growth  of  the  renal  tumor  into  the  renal  vein  or  vena  cava.  One 
should  always  bear  in  mind  tlic  tendency  of  malignant  tumors  to  locate 
secondary  foci  in  bones.  This  must  always  be  thought  of  when 
symptoms  occur,  referable  to  the  extremities,  in   a   patient   suffering. 


3l8  THE   ABDOMEN. 

from  hematuria  and  cachexia,  since  the  metastasis  may  be  the  first 
symptom. 

Differential  Diagnosis  of  Renal  Neoplasms. — i.  Retroperi- 
toneal Sarcoma. — These  lie  nearer  the  median  line  and  cause  but  Httle 
displacement  of  the  colon.  When  they  are  large  they  may  involve  the 
kidney  so  that  a  differentiation  is  impossible. 

2.  Ovarian  Tumors. — The  pedicle  may  often  be  felt  to  be  connected 
with  the  uterus  or  adnexa.  The  intestines  lie  above  and  to  its  outer  side 
(Fig.  1 80).  The  ovarian  tumor,  unless  very  large,  can  be  traced  to  the 
pelvis,  while  a  renal  tumor  appears  to  come  from  beneath  the  costal 
arch  and  causes  bulging  of  the  loin. 

3.  Splenic  Tumors. — These,  if  large  or  when  the  characteristic  shape 
is  obliterated,  may  be  impossible  to  differentiate  (Fig.  189).  If  smaller, 
the  characteristic  notched  edge  and  smooth  surface  aid  in  distinguishing 
them.  In  addition,  the  splenic  tumor  lies  in  front  of  the  inflated  colon 
and  is  not  accompanied  by  hematuria. 

4.  Tumors  of  the  Liver. — When  the  renal  tumor  is  moderately  large 
a  zone  of  resonance  is  found  between  it  and  the  liver.  The  renal  tumor 
causes  more  bulging  of  the  lateral  aspects  of  the  abdomen,  is  accompanied 
by  hematuria  and  blood- casts  of  the  ureter.  Hepatic  tumors  lie  more 
anteriorly  and  in  front  of  the  colon,  unless  the  latter  is  adherent  to  their 
anterior  surface. 


ASCITES. 

The  presence  of  free  serous  fluid  in  the  peritoneal  cavity  may  either 
simulate  or  obscure  the  existence  of  abdominal  tumor  so  that  it  is  neces- 
sary to  recognize  the  physical  signs  caused  by  such  fluid.     These  are: 

1.  Widening  of  the  abdomen. 

2.  A  wave-like  impulse,  upon  tapping  with  the  fingers  of  one  hand, 
felt  by  the  other  hand  laid  flat  upon  the  opposite  side  of  the  abdomen. 

While  the  patient  is  lying  on  his  back  percussion  shows  the  median 
portions  to  be  tympanitic  (Fig.  180).  This  is  the  opposite  of  the  percus- 
sion findings  in  ovarian  cyst  (Fig.  180),  unless  the  latter  is  accompanied 
by  ascites.  When  the  patient  lies  on  one  side,  the  opposite  flank  becomes 
tympanitic,  but  this  changes  to  dullness  when  he  is  rolled  upon  his  back 
again. 

The  diagnosis  of  an  ascites  is  confirmed  by  inserting  a  trocar  in  the 
median  line  midway  between  the  navel  and  symphysis  pubis,  and  ob- 
taining a  clear  straw-colored  fluid  of  low  specific  gravity  containing  a 
small  amount  of  albumin. 


ASCITES. 


319 


In  tuberculous  and  carcinomatous  processes  the  fluid  is  at  times 
hemorrhagic,  but  this  is  inconstant.  In  these  cases  a  multilocular  con- 
dition may  exist  and  more  than  one  puncture  may  be  necessary  to  obtain 
the  fluid.     In  chylous  ascites  the  fluid  is  milky. 

Having  ascertained  the  presence  of  an  ascites,  one  must  attempt, 
either  before  or  after  the 
removal  of  the  fluid,  to  de- 
termine its  cause.  This 
may  be  local  or  gen- 
eral. 
Local: 

(a)  Obstruction  of  the 
portal      circula- 
tion, due  to: 
Cirrhosis     of     the 

liver. 
Neoplasms  of  the 

liver. 
Abdominal  tumors 
which  compress 
the  inferior  vena 
cava  or  portal 
vein. 
{b)  Tuberculous  or 
simple  prolifera- 
tive peritonitis. 

(c)  Neoplasms  of  the 

peritoneum. 

(d)  Tumors  of  the  ab- 

domen— especi- 
ally ovarian 
cysts,  uterine 
fibroids  impact- 
ed in  the  pelvis, 
etc, 

(e)  Obstruction  of  receptaculum  chyli  or  duct  leading  from  it. 
General: 

(a)  Cardiac  affections. 

(b)  Renal  diseases. 

(c)  Chronic  pulmonary  diseases  such  as  emphysema  or  sclerosis. 


Fig.  195. — The  Areas  of  Dullness  in  a  Case  of  Encap- 
sulated Intraperitoneal  Fluid. 
This  illustration  is  the  front  view  of  the  patient  shown  in 
Fig.  196.  I,  Indicates  the  size  of  the  encapsulated  abscess, 
which  was  of  a  tuberculous  nature,  lying  between  the  abdominal 
wall  and  the  agglutinated  coils  of  intestines  within  the  peritoneal 
cavity,  extending  upward  between  the  right  lobe  of  the  hver  and 
the  thoracic  wall.  2,  Indicates  the  area  of  external  prominence 
on  account  of  which  the  case  was  at  first  thought  to  be  one  of 
hydronephrosis. 


320 


THE    ABDOMEX. 


TUMORS  DUE  TO  INFLAMMATORY  EXUDATES  OR  TO  TUBERCULOUS 

PERITONITIS. 

Tumor-like  masses  may  follow  many  of  the  acute  and  chronic  ab- 
dominal affections,  especially  appendicitis  and  inflammations  of  the 
female  pelvic  viscera.     The  tumor- like  induration  around  some  gastric 

ulcers  is  referred  to  on  page 
335.  Massive  exudates  often 
bind  adjacent  coils  of  intes- 
tine together  in  such  a  man- 
ner as  to  closely  simulate  neo- 
plasms on  palpation.  The 
history  of  a  preceding  inflam- 
mation is  of  the  greatest  aid 
in  making  a  diagnosis  in  these 
cases.  Often  some  tender- 
ness and  muscular  rigidity 
coexist. 

Tuberculous  peritonitis  is 
more  fully  discussed  on  page 
343.  It  may  give  rise  to 
tumors  simulating  those  bav- 
ins: their  origin  from  the  var- 
ious  viscera  referred  to  in  this 
section  in  one  of  four  ways. 

(a)  Encapsulated  exu- 
dates (see  Figs.  195  and  196). 

(&)  Through  puckering  of 
the  omentum.  This  causes  a 
transverse,  hard,  elongated 
tumor,  lying  just  above  the 
umbilicus,  although  it  has 
been  found  in  the  right  iliac 
region. 

(c)  In  an  occasional  case,  after  an  ascites  has  been  tapped  one  can 
feel  the  tumor  due  to  contracted  and  adherent  coils  of  intestine  (Fig. 

197)- 

(d)  The  presence  of  tumor-like  masses  in  children  due  to  enlarged 

tuberculous  mesenteric  glands  with  or  without  accompanying  ascites. 

The  diagnosis  may  be  made  if  there  are  tuberculous  foci  elsewhere, 
especially  of  the  cervical  lymph-nodes.     When  this  is  accompanied  by 


Fig.  196. — Enxapsulated  TuBERCuLors  Peritonitis. 
Shaded  area  indicates  the  false  membrane  found  at  the 
time  of  operation,  which  separated  the  abscess  ca\Tty  from 
the  stomach  and  intestines,  which  were  adherent  to  each 
other,  and  pushed  to  the  posterior  and  left  portions  of  the 
abdominal  cavity.  This  is  the  side  view  of  the  same  case 
represented  in  Fig.  195. 


TUMORS  DUE  TO  ANEURYSMS  OF  ABDOMINAL  AORTA.     32 1 

emaciation  and  evening  rise  of  temperature,  the  diagnosis  is  rendered 
almost  certain,  but  both  of  these  may  be  absent,  as  in  the  case  shown  in 
Figs.  195  and  196.  The  tumors  are  often  accompanied  by  pains  and 
digestive  disturbances  in  tuberculosis.  One  should  never  omit  a  rectal 
and  vaginal  examination.  The  history  of  tuberculous  environments  or 
of  eating  the  flesh  or  milk  of  tuberculous  cattle  is  of  value  also. 


TUMORS  DUE  TO  ANEURYSMS  OF  THE  ABDOMINAL  AORTA  OR  ITS 

BRANCHES. 

Aneurysms  of  the  abdominal  aorta  and  its  larger  branches  may  give 

rise  to  palpable  tumors  which,  in  general,  are  readily  recognized.     When 


Tubercles. 


Fig.  197. — Coils  of  Intestine  in  a  Case  of  Tuberculous  Peritonitis. 
The  label  pseudomembrane  leading  to  a  cross  shows  how  these  false  membranes  bind  the  different  coils  of 
intestine  to  each  other.     The  serous  surfaces  of  the  various  coils  show  innumerable  tubercles  covered  by  this  false 
membrane. 


grasped  between  the  thumb,  on  one  side,  and  the  fingers  on  the  other 
(Fig.  385),  these  tumors  have  an  expansile  pulsation  and  a  systolic 
thrill.  Auscultation  shows  a  systolic  murmur.  These  signs  may, 
however,  be  rather  indistinct  if  the  aneurysmal  sac  is  nearly  obliterated. 
Under  such  circumstances  the  tumor  can  be  recognized  as  being  aneurys- 
mal only  by  exclusion  (Fig.  199). 


322 


THE   ABDOMEN. 


In  the  majority  of  cases  it  is  impossible  to  diagnose  aneurysms  of  the 
coeHac  axis,  or  its  branches,  or  of  the  renal  arteries.  When  palpable, 
however,  they  show  the  same  signs  as  do  those  of  the  aorta. 

The  writer  recalls  one  case  of  aneurysm  of  one  of  the  branches  of 
the  superior  mesenteric  artery  which  caused  a  very  mobile  tumor  whose 
nature  was  not  recognized  before  operation. 

Aneurysms  of  the  iliac  arteries  are  often  easily  palpable  (Figs.  198  and 
199).     Those  of  the  external  iliac  cause  a  firm,  immovable  tumor  in  the 

iliac  fossce  whose  nature  can 
be  determined  by  the  pres- 
ence of  the  characteristic  ex- 
pansile pulsation,  of  a  thrill 
and  murmur. 

Differential  Diagnosis. 
— An  unusually  marked  pul- 
sation of  the  abdominal  aorta 
occurring  in  neurasthenics  is 
often  erroneously  diagnosed 
as  an  aneurysm.  It  lacks  the 
typical  expansile  pulsation  of 
an  aneurysm  and  the  thrill  is 
absent. 

Tumors  of  the  pylorus  or 
pancreas  lying  over  the  ab- 
dominal aorta  may  have  ap- 
parent pulsation  through  the 
transmission  to  them  of  the 
arterial  movements.     When 
the  patient  is  placed  in  the 
knee-chest     position,     these 
tumors  of  intraperitoneal  ori- 
gin lose  this  pulsation. 
They  lack  the  expansile  character  of  aneurysm,  and  one  can  usually 
recognize  their  nature  by  the  other  signs,  such  as  the  tests,  etc.,  des- 
cribed. 

Pulsating  tumors  filling  up  the  entire  ihocostal  space  and  lateral  ab- 
dominal regions  are  usually  due  to  the  rupture  of  an  abdominal  aneurysm 
into  the  retroperitoneal  tissues. 


Fig.  198. — View  feom  Right  Side  of  Tumor  of  Abdomen 
(T)  DUE  TO  AN  Aneurysm  of  the  External  Iliac 
Artery. 

Note  the  prominent  varicose  veins  over  the  region  of  the  tro- 
chanter.    This  is  the  same  case  as  shown  in  Fig.  199. 


TUMORS   ARISING   IN   THE   PELVIC  VISCERA. 


323 


ABDOMINAL  TUMORS  HAVING  THEIR  ORIGIN  IN  THE  PELVIC  VISCERA 

OR  BONES. 

Only  those  tumors  are  mentioned  in  which  the  enlargement  is 
sufficient  to  cause  the  growth  to  rise  out  of  the  pelvis. 

I.  Distended  Urinary  Bladder. — In  both  sexes  the  enormously 
distended  urinary  bladder  (Fig.  178)  has  been  mistaken  for  a  neoplasm. 
Ascites,  an  encapsulated  exudate,  and  ovarian  cysts  are  also  among  the 
tumors  with  which  it  has  been  confounded. 

The  diagnosis  may  readily  be  made  from  the  history,  shape  of  the 
tumor,  and  its  position  in  the  median  line  (Fig.  178),  aided,  where  neces- 
sary, by  catheterization,  which  is  followed  by  the  disappearance  of  the 
tumor.     Wherever  any  question  exists,  and,  in  fact,  to  aid  palpation  of 


Fig.  igg. — Lateral  View  of  Tumor  of  Abdomen  due  to  Aneurysm  of  the  External  Iliac  Arterv 

Causing  Prominence  in  Right  Iliac  Region. 

Note  the  extensive  varicose  veins  along  the  outer  aspect  of  the  thigh. 

tumors  of  the  lower  half  of  the  abdomen  in  general,  the  patient  should 
be  catheterized. 

2.  Osteosarcomata. — Sarcomata  arising  from  the  inner  aspect  of 
the  OS  innominatum  must  be  suspected,  if  the  tumor  is  found  in  the 
iliac  fossa,  is  fixed,  hard,  and  gives  the  history  of  rapid  growth. 

3.  Neoplasms  of  Lymph-nodes. — Tumors  arising  from  the  lymph- 
nodes  lying  along  the  pelvic  brim  are  rare  and  are  accompanied  by  evi- 
dences of  a  primary  growth  or  by  inflammatory  symptoms.  They  may 
often  be  palpated  through  the  rectum  or  vagina. 

4.  Tumors  arising  from  the  pelvic  viscera  of  the  female  are  the 
following: 

1.  Pregnant  uterus. 

2.  Large  uterine  myomata  which  extend  into  the  abdominal  cavity. 


324  THE    ABDOMEX. 

3.  Pedunculated  uterine  and  ovarian  tumors. 

4.  Large  ovarian  tumors. 

The  possibility  of  the  presence  of  the  first  named  condition  must 
never  be  forgotten  in  the  diagnosis  of  tumors  of  the  lower  half  of  the  ab- 
domen and  the  signs  of  pregnancy  must  be  sought  for. 

Large  uterine  myomata  are  in  general  of  round  form  and  firm 
consistency.  They  may,  however,  be  quite  soft  and  give  a  sense  of 
fluctuation.  They  can  usually  be  moved  with  the  body  of  the  uterus 
and  if  submucous  are  accompanied  by  severe  menstrual  and  inter- 
menstrual hemorrhages.  When  interstitial,  no  symptoms  are  produced 
except  those  due  to  an  enlarged  uterus. 

Pedunculated  Ovarian  and  Uterine  Tumors. — These  may  have 
such  a  long  pedicle  as  to  permit  the  tumor  to  be  moved  or  palpated, 
as  the  case  may  be,  from  the  pelvis  to  the  costal  arch,  unless  they  are 
fixed  by  adhesions,  under  which  circumstances  it  is  almost  impossible 
to  recognize  their  nature  before  operation.  If  not  thus  fixed,  bimanual 
examination  will  often  reveal  the  pedicle  and  its  relation  to  the  pelvic 
viscera. 

Larger  Ovarian  Tumors. — These,  unless  colossal,  can  be  recog- 
nized by  the  fact  that  they  rise  out  of  the  pelvis,  and  their  pedicle  can 
often  be  traced  toward  the  uterus,  especially  by  bimanual  examination. 

They  cause  contrasting  physical  signs  to  those  of  ascites  unless  ac- 
companied by  the  latter.  These  signs  are  prominence  and  dullness  over 
the  pubes  and  in  the  median  regions,  but  tympany  in  the  flanks  (Fig. 
180). 

The  diagnoses  of  the  various  smaller  pelvic  tumors  arising  from  the 
uterus  and  adnexa  are  not  considered  here,  as  they  are  fully  discussed 
in  the  special  books  on  gynecology. 


Diseases  of  the  Esophagus, 
stricture  of    the   esophagus. 

The  esophagus  extends  from  the  level  of  the  cricoid  cartilage  to  the 
cardiac  end  of  the  stomach.  The  beginning  is  15  cm.,  the  termination 
40  cm.,  from  the  teeth  (Fig.  200).  There  are  certain  points  where  the 
esophagus  is  normally  constricted,  and  these  must  be  borne  in  mind 
when  an  examination  with  bougies  for  a  suspected  stricture  is  made. 
These  narrow  points  are  (Fig.  200) : 

1.  At  the  beginning,  opposite  the  cricoid  or  15  cm.  from  the  teeth. 

2.  Opposite  the  bifurcation  of  the  trachea  or  26  cm.  from  the  teeth. 

3.  Where  it  penetrates  the  diaphragm  or  37  cm.  from  the  teeth. 


STRICTURE    OF    THE    ESOPHAGUS. 


325 


Methods  of  Examination. — The  most  frequently  employed  method 
of  examination  for  esophageal  stricture  is  the  use  of  graduated  bulbous 
bougies  passed  in  the  manner  shown  in  Fig.  201.  Instead  of  the  flexible 
bougie  with  olive  tip,  one  can  use  a  gum-elastic  stomach-tube.     The 


■~D 


Fig.  200. — Normal  and  Pathologic  Conditions  of  the  Esophagus. 
In  all  of  the  diagrams  B  represents  the  bifurcation  of  the  trachea  into  the  two  main  bronchi:  D,  is  the 
diaphragm.,  aijd  S,  cardiac  end  of  the  stomach.  I,  Normal  esophagus:  i,  Showing  the  normal  point  of  narrowing 
at  its  junction  with  the  pharymx;  2,  opposite  the  bifurcation  of  the  bronchi;  3,  at  the  diaphragm.  II,  Loca- 
tion of  most  frequent  diverticula  of  the  esophagus:  H,  Cervical  form  of  pulsion  or  pressure  diverticulum;  M, 
location  of  traction  diverticulum  opposite  bifurcation  of  trachea;  L,  location  of  diverticulum  close  to  car- 
diac end  of  stomach.  Ill,  Sacculated  condition  of  esophagus  or  so-called  idiopathic  dilatation  as  the  result  of 
spasm  of  the  cardiac  end  of  the  esophagus  (cardiospasm).  IV,  Diagrammatic  representation  of  most  frequent 
seats  of  stenosis  or  stricture  of  the  esophagus:  A,  Arch  of  aorta;  i,  stenosis  as  a  result  of  carcinoma  of  the 
lower  end  of  pharynx  and  beginning  of  esophagus;  2,  stenosis  as  a  result  of  pressure  from  tumors  of  the  neck; 
3,  stenosis  as  a  result  of  aneurysm  of  the  arch  of  the  aorta;  4,  stenosis  as  a  result  of  caustic  or  lye  strictures; 
these  latter  may  extend  along  the  entire  length  of  the  esophagus;  5,  stenosis  as  a  result  of  carcinoma  of  the 
lower  end  of  the  esophagus  and  cardiac  end  of  stomach. 


patient  should  be  seated  on  a  low  chair  with  head  bent  backward.  Hold- 
ing the  patient's  tongue  down  with  the  index-linger  of  the  left  hand,  the 
bougie  is  passed  directly  back  to  the  posterior  wall  of  the  pharynx,  where 
the  resistance  prevents  further  progress  in  that  direction.     The  bougie  or 


326 


THE    ABDOMEN. 


gum-elastic  stomach-tube  is  then  directed  downward,  great  care  being 
employed  to  avoid  perforating  a  carcinomatous  area  or  a  diverticulum. 
It  is  advisable  to  begin  Vvdth  a  large  size  and  reduce  the  caHber  if  it  is 
impossible  to  pass  the  first  one.  The  esophagoscope  has  been  employed 
for  the  purpose  of  locating  strictures  by  Gottstein  and  others,  but  re- 
quires great  dexterity  and  famiharity  with  it,  so  that  for  general  pur- 
poses we  rely  on  the  above  two  methods. 

When  a  genuine  resistance  is  met  the  bougie  is  withdrawn  and  the 
distance  of  the  stenosis  from  the  teeth  is  noted. 

Other  methods  of  locating  strictures,  such  as  auscultation  posteriorly 
while  the  patient  swallows  water,  are  seldom  employed  and  are  not  so 


Fig.  201. — Method  of  PAssmo  Esophageal  Bougies  in  Order  to  DETERiONE  the  Le\'el  of  a  Stric- 
ture. 
Note  how  the  patient's  head  is  held  slightly  backward,  the  left  hand  being  placed  upon  the  forehead,  while 
the  right  hand  grasps  the  bougie  in  a  manner  similar  to  that  of  holding  a  penholder,  no  force  being  used. 

reliable  as  the  passage  of  bougies.  In  every  case  it  is  advisable,  in  addi- 
tion to  instrumental  examination,  to  insert  the  index-finger  into  the 
pharynx,  because  one  may  be  able  to  palpate  a  malignant  growth  at  the 
beginning  of  the  esophagus.  An  attempt  should  be  made  to  recognize 
not  only  the  location  but  also  the  nature  of  the  stricture  if  one  exists. 

Within  recent  years  bismuth  and  similar  substances  which  give  a 
shadow  in  a  skiagraph  have  been  employed  to  locate  strictures  of  the 
esophagus,  and  also  in  cases  of  diverticula  and  dilatation.  The  patient 
is  given  about  one  ounce  of  bismuth  subnitrate  mixed  with  bread  or 
potato  and  instructed  to  swallow  it.  The  substance  lodges  above  the 
point  of  stenosis,  as  shoT\'n  in  Fig.  202,  causing  a  distinct  shadow  in 


STRICTURE    OF   THE    ESOPHAGUS. 


327 


cases  of  dilatation.  One  gets  a  spindle-shaped  shadow  corresponding  to 
the  extent  of  the  dilatation.  Another  method,  to  be  referred  to  below, 
is  also  used,  and  this  consists  in  having  the  patient  swallow  a  bag  filled 


Fig.  202. — ^X-RAY  OF  a  Case  of  Stp.icture  of  the  Esophagus  Opposite  the  Bifurcation  of  the  Trachea. 
The  outlines  of  the  bismuth  shadow  have  been  traced  in  white. 


with  shot,  which  gives  rise  to  a  shadow  at  the  point  of  stenosis  or  within 
the  sac  of  the  diverticulum. 

Diagnosis. — The  diagnosis  of  esophageal  stricture  in  general  may- 
be made  from  the  following: 


328  THE    ABDOMEX. 

1.  History  of  difficulty  in  swallowing  accompanied  by  the  regurgita- 
tion of  food  or  mucus,  often  mixed  with  blood. 

2.  History  of  some  etiologic  factor  mentioned  below  under  the  head 
of  cicatricial  or  extra-esophageal  or  malignant  causes.  The  exclusion 
of  a  neurotic  cause  of  the  stenosis  must  always  be  made. 

3.  The  results  of  the  local  examination  with  the  bougies,  stomach- 
tubes,  esophagoscope,  or  an  .r-ray  after  bismuth  has  been  swallowed. 

The  diagnosis  of  the  cause  of  the  stricture  may  be  made  by  excluding 
the  following  in  their  order: 

1.  Cicatricial  Strictures. — These  give  the  histor\-  of  having  swallowed 
caustic  liquids  or  having  had  some  disease  which  could  produce  esopha- 
geal ulcerations,  such  as  syphilis  or  typhoid  fever.  The  bougie  meets  a 
firm  resistance  which  responds  readily  to  treatment  by  graduated  bougies. 

2.  Strictures  due  to  Pressure  jrom  External  Causes. — This  group  in- 
cludes pressure  upon  the  esophagus  from  aneurysm  of  the  arch  of  the 
aorta,  enlarged  cervical  or  retrosternal  goiter,  especially  when  mahgnant, 
enlarged  cervical  and  bronchial  glands,  tumors  of  the  neck  or  mediastinal 
tissues,  rarely  pericardial  effusions,  and  lastly  by  esophageal  diverticula. 

It  is  unnecessar}'  to  consider  the  diagnosis  of  these  various  extra- 
esophageal  causes  of  strictures  here,  as  they  are  discussed  under  the  re- 
spective headings. 

3.  Carcinomatous  or  Malignant  Strictures. — This  is  by  far  the  com- 
monest cause  of  stricture  of  the  esophagus  in  patients  above  forty,  and 
especially  after  the  age  of  fifty  years. 

The  dysphagia  common  to  all  strictures  appears  in  carcinoma,  gradu- 
ally accompanied  by  progressive  emaciation  and  loss  of  strength.  The 
other  s}Tiiptoms  x3lTX  according  to  the  situation  of  the  carcinoma. 

(a)  If  at  the  beginning  of  the  esophagus  (Fig.  200)  there  is  immediate 
regurgitation  of  the  food  and  early  enlargement  of  the  cervical  lymph- 
nodes.  In  one  case  recently  seen  the  patient  consulted  the  writer  in  re- 
gard to  the  tumor  of  the  neck  before  the  dysphagia  had  become  suffi- 
ciently marked  to  attract  his  attention. 

(b)  If  the  cancer  is  situated  at  the  level  of  the  bifurcation  of  the 
trachea,  hoarseness  and  aphonia  are  marked. 

(c)  If  situated  close  to  the  cardiac  end  the  regurgitation  of  food 
occurs  much  later,  often  ten  to  fifteen  minutes  after  being  swallowed. 

The  bougie  is  arrested  at  the  beginning  of  the  carcinoma  and  no 
force  should  be  employed  in  passing  through  it.  A  sudden  improvement 
in  the  stenosis  symptoms,  points  to  ulceration  of  the  cancer.  Late 
sequelae  of  malignant  stricture  are  perforations  into  the  pleural  ca\'itv  or 
mediastinum. 


DIVERTICULA    OF    THE    ESOPHAGUS.  329 

4.  Spasmodic  Stricture. — This  fourth  variety  of  stricture  is  com- 
paratively rare  and  can  usually  be  distinguished  from  the  cicatricial, 
extra-esophageal,  and  malignant  forms  by  the  history  and  the  physical 
examination.  The  spasmodic  strictures  occur  in  nervous  hysterical 
women,  but  may  occur  in  elderly  men,  and  are  often  associated  with 
hypochondriasis  or  true  hysteria.  The  bougie  is  often  temporarily 
arrested  at  the  point  of  spasm,  but  by  waiting  a  short  time  it  can  be 
passed  through  the  stricture  readily,  especially  under  anesthesia. 


DIVERTICULA  OF  THE  ESOPHAGUS. 

There  are  two  varieties: 

1.  Traction  diverticula  situated  on  the  anterior  wall  opposite  the 
bifurcation  of  the  trachea.  They  are  caused  by  cicatrices  resulting 
from  bronchial  lymph-node  or  pleuropericardial  inflammation,  drawing 
the  anterior  wall  out. 

This  form  cannot  be  diagnosed  unless,  as  rarely  occurs,  food  collects 
within  the  sac  so  that  a  pressure  diverticulum  is  formed. 

2.  Pressure  diverticula  occur  in  three  places : 

(a)  In  the  pharynx,  causing  at  times  a  tumor  in  the  neck,  referred 
to  on  page  177,  which  can  be  emptied  when  filled  with  food.  This  is 
the  most  frequent  form. 

{h)  At  the  bifurcation  of  the  trachea  developing  from  a  traction 
diverticulum. 

(c)   Just  above  the  diaphragm. 

The  diagnosis  of  a  diverticulum  of  the  pharynx  may  be  readily  made 
if  there  is  a  history  of  a  tumor  of  the  neck,  most  often. on  the  left  side, 
which  develops  during  eating,  can  be  emptied  by  pressure,  and  is  ac- 
companied by  the  regurgitation  of  food.  A  bougie  is  arrested  at  the 
cricoid  and  may  be  passed  into  the  sac  and  freely  moved  about,  so  that 
the  tip  can  be  felt  in  the  neck.  If  situated  lower  down,  other  means  of 
diagnosis  are  employed,  and  the  condition  must  be  differentiated  from 
stricture  and  dilatation  of  the  esophagus,  because  in  all  three  the  symp- 
toms of  regurgitation  of  food  ar£  present. 

The  methods  of  diagnosis  at  present  employed  to  differentiate  these 
three  varieties  of  pressure  diverticulum  are : 

1.  The  use  of  bismuth  or  similar  shadow-producing  substances  and  a 
'skiagraph.     If  the  patient  is  allowed  to  swallow  a  bag  of  bird-shot  or  a 

mixture  of  bismuth  and  bread,  it  often  enters  the  diverticulum  and  gives 
rise  to  a  distinct  shadow. 

2.  A  bougie  enters  the  opening  of  the  diverticulum,  if  the  latter  is 


33©  THE   ABDOMEN. 

full,  and  is  arrested  there,  but  meets  with  no  obstruction  and  passes  into 
the  stomach,  if  the  sac  is  empty.  This  intermittent  arrest  of  the  bougie 
is  characteristic  of  deep-seated  diverticula. 

One  tube  can  at  times  be  passed  into  the  diverticulum  and  a  second 
alongside  of  it  into  the  stomach.  If  different  colored  fluids  are  poured 
into  them  separately,  they  will  return  unmixed. 

3.  The  esophagoscope  often  shows  the  opening  of  the  diverticulum, 
but,  as  stated  above,  its  employment  requires  considerable  skill  and 
practice.  A  deep-seated  diverticulum  is  distinguished  from  a  stricture 
by  the  fact  that  the  arrest  of  the  bougie  is  intermittent  in  the  former  and 
constant  in  the  latter.  (See  method  i,  above.)  It  may  be  differentiated 
from  a  diffuse  dilatation  either  by  the  skiagraph  or  the  Rumpel  test, 
which  is  as  follows : 

A  tube  with  lateral  openings  is  passed  into  the  stomach,  while  a 
second  one  is  passed  into  the  diverticulum.  If  there  is  dilatation,  colored 
fluid  poured  into  the  tube  at  the  point  of  enlargement  will  flow  through 
the  lateral  openings  into  the  stomach.  If  a  diverticulum  is  present  noth- 
ing will  flow  out  of  the  tube  in  the  stomach,  while  from  the  tube  in  the 
diverticulum  all  the  fluid  poured  in  will  be  recovered. 

IDIOPATHIC  DILATATION  OF  THE  ESOPHAGUS. 

This  frequently  follows  a  spasm  of  the  lower  end  of  the  esophagus. 
The  lumen  may  become  enormously  dilated,  so  that  when  a  bougie  is 
passed  it  meets  with  no  obstruction  but  has  a  very  wide  range  of  motion. 
A  skiagraph  taken  after  the  ingestion  of  bismuth  often  shows  a  spindle- 
like shadow.  The  esophagus  wiU  hold  500  Cc.  of  fluid  uistead  of  100 
Cc.  of  fluid.  In  the  majority  of  cases  the  patients  suffer  from  diffi- 
culty in  swallowing,  and  from  regurgitation  of  food  soon  after  eating  or 
several  hours  later.  There  is  great  fetor  and  a  feeling  of  oppression 
in  the  thorax  which  is  only  relieved  by  vomiting.  The  regurgitated  food 
contains  no  HCl,  but  an  excess  of  lactic  acid. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS. 

These  may  be  divided  into  those  which  are  rough  and  those  which  are 
smooth.  The  former  cause  both  obstruction  and  injury  to  the  wall  of 
the  esophagus,  while  the  latter  only  cause  obstruction.  If  situated  high 
up  near  the  opening  of  the  glottis,  foreign  bodies,  like  chunks  of  meat, 
may  cause  asphyxia.  If  they  are  smaller  they  give  rise  to  attacks  of 
cyanosis  and  suffocation.  If  the  foreign  body  is  sharp  it  causes  pain 
which  is  often  referred  to  the  sternum. 


SURGICAL   DISEASES    OF   THE    STOMACH.  33I 

The  diagnosis  may  be  made  from  (a)  the  history,  in  the  majority  of 
cases;  (b)  examination  by  the  various  methods  to  be  mentioned;  and 
(c)  the  symptoms  of  dysphagia,  pain,  and  appearance  of  periesophageal 
abscesses  due  to  perforation  of  the  wall  and  infection  of  the  surround- 
ing connective  tissue. 

The  methods  of  examination  are  (a)  the  passage  of  an  olive-tipped 
bougie,  which  is  arrested  where  the  foreign  body  is  lodged  unless  its 
convex  surface  lies  in  the  concavity  of  the  anterior  wall. 

(b)  Esophagoscopy. 

(c)  A  skiagraph  is  very  valuable  if  the  foreign  body  is  a  metallic  one. 

(d)  The  finger  should  be  inserted  into  the  beginning  of  the  esophagus 
and  the  laryngeal  mirror  used. 


Other  Abdominal  Conditions. 

In  the  preceding  sections  an  effort  has  been  made  to  group  affections 
as  they  present  themselves  when  we  are  called  to  the  bedside  of  a 
patient  to  make  a  diagnosis. 

As  stated  in  the  preface,  it  was  thought  by  the  author  that  such  a 
grouping  more  nearly  meets  with  clinical  conditions  than  would  one  in 
which  the  injuries  or  diseases  of  each  viscus  were  discussed  separately. 

It  is  impossible,  however,  to  consider  every  condition  under  the  heads 
of  Traumatisms,  Acute  Affections,  and  Tumors  of  the  Abdominal 
Viscera,  so  that  it  will  now  be  necessary  to  take  up  the  remaining  dis- 
eases which  are  of  interest  from  a  surgical  standpoint. 


SURGICAL  DISEASES  OF  THE  STOMACH. 
Dilatation  of  the  Stomach. 

This  occurs  acutely,  as  a  postoperative  condition  (see  Chapter  on 
Post-operative  Complications),  or  in  a  chronic  form.  The  latter  results 
from  congenital  or  acquired  stenosis  of  the  pylorus. 

In  congenital  stenosis  the  diagnosis  may  be  made  from  the  history 
and  the  physical  examination.  It  usually  begins  in  the  first  weeks  of 
life.  The  baby  is  unable  to  retain  any  or  very  little  food  and  vomits  very 
frequently.  If  the  emesis  is  accompanied  by  diarrhea  with  much  mucus 
and  undigested  milk  in  the  stools,  the  condition  must  be  differentiated 
from  gastro-enteritis. 

It  is  possible  to  see  the  peristaltic  waves  passing  across  the  epigastric 
and  umbilical  regions  when  the  stomach  is  filled. 

If  in  addition  to  the  constant  vomiting  and  visible  peristalsis  one  is 


332  THE    ABDOilEX. 

able  to  palpate  a  mass  just  below  the  right  costal  arch  corresponding  to 
the  hypertrophied  pylorus,  the  diagnosis  is  certain.  Unfortunately,  in 
many  of  the  cases  the  peristalsis  and  tumor  are  not  detected  until  the 
disease  is  well  advanced.  This  condition  must  always  be  borne  in  mind 
when  there  is  a  histor}^  of  repeated  vomiting  immediately  after  the  m- 
gestion  of  food  in  emaciated  infants,  whether  breast-fed  or  bottle-fed. 

Acquired  stenosis  is  most  often  the  result : 

{a)  Of  stricture  or  adhesions  following  the  healing  of  a  round  ulcer. 

(h)   Of  mahgnant  disease  of  the  pylorus. 

(c)    Of  gastric  atony. 

The  diagnosis  of  gastric  dilatation,  whether  congenital  or  acquired,  is 
readily  made  from  the  following: 

Vomiting  is  the  most  prominent  symptom.  At  varying  intervals, 
ordinarilv  every  two  or  three  days,  an  enormous  quantity  of  Hquid 
mixed  w^ith  undigested  food,  and  of  an  offensive  odor  is  brought  up.  In 
the  intervals  there  is  complaint  of  oppression  after  eating,  eructations  of 
gas,  and  thirst.     Tetany  may  occur  as  an  early  symptom. 

When  the  stomach  is  full  one  can  easily  demonstrate  a  splashing 
sound  on  succussion.  The  outlines  of  the  distended  organ  are  often 
\dsible  and  peristaltic  waves  can  be  seen  passing  across  it  toward  the 
pylorus.  VChen  the  stomach  is  inflated  with  air  the  outlines  become  verv- 
plain.  In  gastroptosis  both  the  lesser  and  greater  curvatures  are  at  a 
lower  level,  while  in  dilatation  the  lesser  remains  almost  normal,  ahhough 
the  greater  may  even  be  as  low  as  the  symphysis  pubis.  A  history  of 
manv  vears'  duration,  preceded  by  severe  pain  after  eating  and  either 
melena  or  hematemesis,  speaks  for  ulcer  as  the  cause  of  the  obstruction. 
Rapid  emaciation,  absence  of  HCl  in  the  vomit,  palpation  of  a  tumor, 
speak  for  malignancy.  Adhesions  rarely  cause  a  marked  degree  of 
dilatation. 

Gastric  and  Duodenal  Ulcer. 

Symptoms. — In  many  cases  the  presence  of  this  condition  is  not 
suspected  until  there  is  hemorrhage  from  the  stomach  or  bowels  or 
symptoms  of  perforation  occur  (page  266).  In  other  cases  there  is  a 
characteristic  group  of  symptoms  from  which  the  diagnosis  is  made. 
They  are  as  follows : 

Pain. — This  is  either  felt  soon  after  the  ingestion  of  food  in  gastric, 
or  one  to  two  hours  later  in  duodenal  ulcer.  The  pain  is  usually  well 
localized  in  the  epigastrium,  but  may  radiate  to  the  back  and  sides.  Dur- 
ing the  painless  interv^al  there  is  tenderness  on  pressure  over  the  epi- 
gastrium. 


SURGICAL    DISEASES    OF   THE    STOMACH.  333 

Hemorrhage. — This  may  be  latent  and  only  be  found  by  examination 
of  the  stomach  contents.  In  many  of  the  cases  of  acute  ulcer,  the  hemor- 
rhage is  profuse  and  is  vomited  as  bright  red  fluid  blood.  This  may  oc- 
cur only  once  or  be  repeated  at  intervals  for  years.  In  duodenal  ulcer 
the  patient  may  suddenly  collapse,  or  feel  faint  and  pass  large  quanti- 
ties of  tarry  blood  in  his  stools. 

Dyspeptic  Symptoms,  Nausea  and  Vomiting. — The  degree  of  the 
symptoms  of  indigestion  varies  greatly.  They  may  be  insignificant 
or  very  marked.  Vomiting  one  to  four  hours  after  eating  is  frequent  in 
gastric  ulcer,  and  in  both  the  stomach  contents  frequently  show  hyper- 
chlorhydria. 

Differential  Diagnosis. — Gastralgia. — The  area  of  tenderness  is 
more  locahzed  in  ulcer  and  present  during  the  intervals  of  the  attacks 
of  pain.  Hyperacidity  is  a  more  constant  finding  in  ulcer,  while  in 
gastralgia  it  may  be  present  or  there  be  deficient  HCl.  In  many  cases 
of  ulcer  there  is  a  history  of  hemorrhages  and  of  dilatation.  Dyspeptic 
symptoms  and  vomiting  in  the  intervals  of  pain  are  more  characteristic 
of  ulcer. 

Carcinoma  oj  the  Stomach. — This  is  considered  elsewhere  (page  335). 

Epigastric  Hernia. — This  is  referred  to  on  page  420. 

Gallstones. — The  attacks  of  pain,  as  a  rule,  occur  independently  of 
the  ingestion  of  food,  are  located  over  the  region  of  the  gallbladder,  and 
are  accompanied  by  rigidity.  The  attack  of  bihary  colic  begins  suddenly 
and  the  pain  is  far  more  severe  than  that  of  ulcer.  It  radiates  to  the 
right  shoulder,  and  the  vomiting  which  accompanied  it  persists  after  the 
stomach  is  empty.  If  the  ulcer,  as  is  most  often  the  case  (Fig.  203),  is 
situated  on  the  posterior  wall  near  the  pylorus,  there  is  a  localized  tender 
spot  between  the  right  costal  margin  and  middle  line,  unless  a  gastroptosis 
exists,  while  in  gallstones  the  tenderness  and  pain  are  further  to  the  right 
(Fig.  167). 

Ulcer  of  Stomach  versus  Ulcer  oj  Duodenum. — It  is  almiost  impossible 
to  distinguish  these  clinically.  Duodenal  ulcers  are  more  frequent  in 
men  after  middle  age,  the  pain  occurs  one  to  two  hours  after  ingestion 
of  food  and  is  referred  to  the  j-ight  hypochondrium.  Intestinal  hemor- 
rhage occurs  after  gastralgic  attacks  with  hematemesis  in  duodenal  ulcer. 
But  all  of  these  may  occur  in  gastric  ulcer  (which,  however,  is  more 
common  in  women  under  thirty),  so  that  an  absolute  differentiation  is 
impossible. 

Diagnosis  of  the  Complications  of  Gastric  and  Duodenal 
Ulcer. — I.  Perjoration  was  referred  to  in  the  section  on  acute  abdominal 
affections,  page  266. 


334  THE   ABDOMEN. 

2.  Perigastric  Abscess  due  to  Perforation  (Left  Subphrenic  Abscess). — 
The  diagnosis  is  dependent  on  the  history  of  the  ulcer,  as  given  above, 
followed  by  acute  symptoms  of  a  localized  peritonitis,  usually  of  a  left 
subphrenic  abscess.  There  is  a  history  of  perforation  followed  by  ir- 
regular fever,  tenderness  over  the  left  upper  quadrant  of  the  abdomen 
combined  with  physical  signs  over  the  lower  part  of  the  left  side  of  the 
chest,  as  in  empyema.  Occasionally  induration  and  tenderness  are 
present  in  the  epigastrium.  If  a  retroperitoneal  abscess  form,  the  pus 
may  burrow  toward  the  lumbar  region  and  cause  fluctuation  here.     Gas 


Fig.  203. — MULTIPLE' Ulcers  of  Posterior  Wall  of  Stomach. 
P,  Pylorus.     By  following  the  illustration  downward  from  this  letter,  one  can  note  the  rather  sharp  de- 
marcation between  the  gastric  mucous  membrane,  on  which  the  ulcers  are  situated,  and  the  duodenum,  shown 
at  D.     I,  2,  3,  and  4  are  typical  round  ulcers  showing  great  variation  in  size,  situated  on  the  posterior  wall 
of  the  stomach. 

is  more  frequently  present  in  left  than  in  right  subphrenic  abscess,  so 
that  above  the  dullness  there  is  tympany.  Unless  there  is  an  accompany- 
ing pleuritic  effusion,  breath  sounds  are  heard  above  the  upper  level  of 
dullness  and  there  is  respiratory  mobility.  The  three  zones  of  normal 
lung  resonance,  tympany  and  dullness  are  well  shown  in  Fig.  i66. 

3.  Hour-glass  Stomach. — This  follows  cicatrization  of  an  ulcer.  The 
diagnosis  may  be  made  from  the  following  signs  and  tests  as  given  by 
Moynihan : 

First,  when  fluid  is  introduced  into  the  stomach  it  seems  to  disap- 


SURGICAL    DISEASES    OF    THE    STOMACH.  335 

pear  altogether,  and  is  not  returned  through  the  tube.  Second,  when 
the  stomach  is  washed  out,  until  the  fluid  returns  clear,  there  is  a  sudden, 
unlooked-for  gush  of  foul  or  often  putrid  fluid.  Third,  on  distending  the 
stomach  with  carbon  dioxid,  the  bubbling  and  gushing  of  fluid  through 
a  narrow  chink  can  be  heard  with  a  stethoscope.  Fourth,  there  may  be 
a  distinct  visible  or  palpable  sulcus  separating  two  dilated  cavities. 

Perigastric  Adhesions. — These  may  be  recognized  by  symptoms  of 
chronic  indigestion  or  pyloric  obstruction  of  slight  degree,  by  slight  tender- 
ness over  the  epigastrium,  and  the  occasional  presence  of  palpable  tumor. 
There  is  often  a  history  of  gastric  ulcer  (in  40  per  cent,  of  the  cases) 
or  of  gallstones,  or  less  frequently  of  tuberculosis.  The  tumor  may  re- 
semble that  of  cancer,  but  is  never  accompanied  by  the  progressive 
emaciation  of  the  latter  condition.  The  course  is  very  chronic  and  is 
frequently  accompanied  by  evidences  of  biliary  stasis  and  absorption. 

Carcinoma  of  the  Stomach. 

The  presence  of  this  condition  is  diagnosed  if,  in  a  patient  above  the 
age  of  forty,  with  or  without  the  history  of  ulcer,  signs  of  digestive  dis- 
turbances appear  accompanied  by  pain,  anemia,  loss  of  weight,  and 
vomiting. 

The  most  important  points  in  making  a  diagnosis  are: 

{a)  The  history  of  steady,  progressive  loss  of  weight. 

{h)  The  presence  of  a  secondary  anemia,  both  red  corpuscles  and 
hemoglobin  being  reduced. 

(c)  Pain.  This  is  an  early  and  important  symptom  according  to 
Osier,  and  was  present  in  130  to  150  cases.  At  first  only  a  heaviness 
after  eating  is  noticed,  but  later  it  is  of  a  dull,  gnawing  character  re- 
ferred to  the  epigastrium.     There  is  marked  local  tenderness. 

{d)  Vomiting.  This  is  also  very  constant.  It  occurs  earliest  when 
the  tumo'r  is  near  the  pylorus,  from  one  to  two  hours  after  the  taking  of 
food.     At  first  it  is  infrequent,  but  later  is  almost  constantly  present. 

(e)  Hemorrhage.  This  rarely  occurs  as  bright  red  blood,  but  most 
frequently  in  smaller  quantities,  giving  the  vomitus  the  typical  "coffee- 
ground"  appearance. 

(/)  Stomach  contents.  An  analysis  of  the  stomach  contents  after 
a  test  meal  has  been  given  should  be  made  on  several  occasions  at  short 
intervals  in  order  to  draw  accurate  conclusions. 

The  constant  absence,  or  great  reduction  of  hydrochloric  acid  and 
the  presence  of  lactic  acid  are  strongly  indicative  of  cancer.  Unfortu- 
nately, these  data  are  often  so  late  in  their  appearance  as  to  be  of  little 
value  unless  present  quite  early. 


00^ 


THE    ABDOMEN. 


On  the  other  hand,  carcinoma  may  exist  although  hydrochloric  acid 
is  present.  The  latter  is  the  condition  frequently  found  in  cases  of 
carcinoma  developing  upon  a  round  ulcer  (Fig.  204). 

The  presence  of  the  Oppler-Boas  bacillus  is  of  shght  value,  but  the 
detection  of  lactic  acid  in  the  stomach  contents  after  a  Boas  test  meal  is 
of  greater  value.  The  constant  presence  of  blood  intimately  mixed  v^ith 
the  gastric  contents  is  also  of  great  importance,  especially  if  vomited 
alone;  as  hydrochloric  acid  is  absent  in  cases  of  chronic  gastritis  or 
atrophy  of  the  mucosa,  the  value  of  the  presence  of  blood  is  apparent. 


Fig.  204. — CARCiNOiiA  of  Stomach  Developing  upon  Round  Ulcer. 
This  is  the  primary  tumor  whose  metastases  are  seen  in  the  liver  in  Fig.  185.     C,  Observe  the  sharp  de- 
marcation between  the  carcinoma  and  the  surrounding  normal  mucous  membrane  of  the  stomach.      D,  Mucous 
membrane  of  duodenum.     Observe  the  pro.ximity  of  the  carcinoma  to  the  pylorus.     G,  Lymph-nodes  along 
gastrohepatic  omentum. 


ig)  Tumor.  This  is  the  most  important  symptom,  but,  like  the 
changes  in  the  stomach  contents,  is  often  only  present  at  a  late  stage. 
The  surface  is  usually  smooth. 

Unless  adhesions  exist  a  tumor  of  the  stomach  is  freely  movable 
(Fig.  181)  and  is  best  felt  when  the  stomach  is  empty.  Usually  the 
tumor  is  located  in  the  epigastric  or  umbilical  regions,  but  in  gastroptosis 
may  be  in  the  right  iliac  region  (Fig.  183).  The  presence  of  an  ascites 
may  render  the  palpation  of  a  tumor  impossible  until  the  fluid  is  aspirated, 
and  this  should,  of  course,  be  done. 


GALLSTONES.  337 

GALLSTONES. 

Many  cases  of  cholelithiasis  are  either  not  recognized  during  life  or 
they  are  found  as  an  accessory  condition  in  operations  for  other  intra- 
abdominal lesions. 

Cases  in  which  a  diagnosis  is  possible,  occur  clinically  in  different 
forms,  as  follows : 

1.  Those  seen  during  an  attack  of  biliary  colic  or  of  empyema  of 
the  gallbladder. 

2.  Those  showing  evidences  of  a  complete  occlusion  of  the  cystic 
duct  by  a  calculus. 

3.  Symptoms  of  common  duct  calculi  with  or  without  accompanying 
infection. 

4.  Cases  seen  in  the  interval  between  active  symptoms  pointing  to 
the  bile-passages. 

The  diagnosis  of  the  first  and  second  classes  of  cases  has  been  re- 
ferred to  on  pages  247  and  297,  respectively. 

3.  Common  Duct  Stones. — A  stone  passing  through  the  common 
duct  may  give  rise  to  colic  which  cannot  be  distinguished,  during  the  at- 
tack, from  that  due  to  the  passage  of  one  through  the  cystic  duct.  The 
most  frequent  location  for  common  duct  calculi  is  near  the  ampulla. 
The  diagnosis  must  be  made  between  one  of  two  forms,  according  to 
whether  the  lumen  is  completely  or  incompletely  occluded. 

(a)  Those  causing  complete  obstruction.  These  are  rare  and  may  be 
recognized  by  the  fact  that  the  jaundice  is  deep  and  constant  and  there 
are  no  evidences  of  intrahepatic  infection,  as  in  the  next  group.  They 
must  be  differentiated  from  new-growths  pressing  on  the  common  duct 
by  the  absence  of  emaciation,  and  of  symptoms  indicative  of  cancer  of 
the  pancreas  (page  303)  or  of  the  pylorus  (page  335). 

(b)  Those  causing  incomplete  obstruction  due  to  a  ball-valve  action 
of  the  calculus.  This  is  the  more  frequent  form  and  is  often  accompanied 
by  attacks  of  pain  and  chills  at  irregular  intervals  followed  by  high  fever 
and  a  sweat.  Jaundice  becomes  marked  and  the  liver  may  be  enlarged 
and  tender.  In  a  late  stage  the  gallbladder  itself  is  contracted  in  the 
majority  of  cases.  A  ball-valve-like  common  duct  stone  may,  however, 
occur  without  infection  of  sufficient  intensity  to  cause  symptoms.  The 
diagnosis  may  then  be  made  from  the  history  of  previous  attacks  of 
biliary  colic  and  by  variations  in  the  intensity  of  the  jaundice. 

Differential  Diagnosis. — These  attacks  of  rigors,  etc.,  so  closely 
resemble  those  of  malaria  that  a  mistake  in  diagnosis  has  often  been  made. 
Malarial  paroxysms  occur  with  more  regularity  and  are  less  frequently 


338  THE   ABDOMEN. 

accompanied  by  jaundice,  which,  when  present,  is  not  deep.  Nor 
is  pain  over  the  hypochondrium  present,  and  unless  quinin  has  been 
given,  Plasmodia  can  be  found.  There  is  also  no  leukocytosis  in  malaria, 
and  the  spleen  is  enlarged.  Exceptionally  plasmodia  are  not  found  until 
quinin  has  been  given. 

The  presence  of  jaundice  between  the  chills,  and  of  clay-colored 
stools,  should  always  direct  attention  to  the  possibility  of  gallstones,  for 
which  the  stools  must  be  searched. 

The  diagnosis  of  suppurative  cholangitis  has  already  been  referred 
to  (page  249).  The  septic  intoxication  is  more  marked,  the  fever  is  of 
a  more  continuous  type,  the  liver  is  enlarged  and  tender,  and  recovery 
does  not  occur. 

4.  Diagnosis  During  the  Interval. — It  is  this  class  of  cases  in 
which  the  recognition  of  the  condition  is  often  most  difficult,  for  one  has 
only  the  history  and  the  results  of  the  physical  examination  upon  which 
to  make  a  diagnosis. 

History. — This  is  of  the  greatest  importance,  since  many  cases  as- 
sumed for  years  to  be  gastralgia,  indigestion,  or  intestinal  colic,  or  even 
gastric  ulcer,  are  now  found  to  be  cases  of  gallstones. 

The  history  should  be  directed  toward  the  following  points  : 

1.  Has  pain  been  present  at  any  time?  If  so,  one  should  secure  a 
detailed  description  of  the  attacks  and  compare  it  vnth  those  of  typical 
biliary  colic. 

Such  paroxysms  of  pain  are  less  frequently  obsen-ed  than  is  a  dull 
aching  pain  referred  to  the  gallbladder.  This  dull  pain  is  increased  by 
taking  food,  but  is  relieved  by  vomiting  or  by  pressure  over  the  gall- 
bladder. 

The  biliary  colic  pain  is  acute  in  its  onset,  very  severe,  and  disappears 
suddenly,  while  the  dull  pain  above  referred  to  is  more  or  less  continuous. 
Radiation  to  the  shoulders  occurs  in  both  of  these  varieties  of  gallstone 
pain. 

2.  What  alimentary  symptoms  have  accompanied  the  pain  ?  In  the 
majority  of  cases  there  is  a  history  of  nausea  and  vomiting,  accom- 
panying the  more  severe  variety  of  pain,  or  there  is  a  histor}^  of  long- 
continued  digestive  disturbances  with  dull  pain  over  the  gallbladder. 
Jaundice  occurs  so  rarely  in  gallstones  that  its  absence  in  the  history 
must  not  permit  one  to  think  of  excluding  gallstones.  This  is  especially 
true  of  stones  in  the  gallbladder  and  cystic  duct.  Jaundice,  if  of  slight 
degree,  is  difficult  to  detect.  A  good  plan  is  to  look  at  the  roof  of  the 
mouth  at  the  back  of  the  hard  palate,  where  it  is  often  visible,  if  no- 
where else.     It  is  also  important  to  inquire  in  regard  to  the  presence  or 


GALLSTONES. 


339 


absence  of  bile  in  the  stools.  The  jaundice  due  to  carcinoma  of  the 
head  of  the  pancreas  or  to  a  calculus  completely  obstructing  the  com- 
mon duct  is  persistent  and  progressive. 

3.  Have  fever,  chills,  and  sweats  been  present  at  any  time?  Ir- 
regular paroxysms  of  these  three  symptoms,  especially  if  accompanied 
by  jaundice  which  varies  greatly  in  degree,  speak  for  common  duct  stone. 
Continued  fever  with  but  slight  remissions  indicates  an  empyema  of  the 
gallbladder. 

Physical  Examination. — Palpation  of  the  Gallbladder  Region. — 


Fig.  205. — Method  of  Examination  to  Elicit  Tenderness  of  Gallbladder  (Moynihan). 


One  can  often  detect  hypersensitiveness  of  the  gallbladder  by  pressing 
the  fingers  down  upon  the  gallbladder  as  shown  in  Fig.  179  or  by  the 
method  described  by  Mo}Tiihan  and  shown  in  Fig.  205.  In  the  latter 
procedure,  while  sitting  to  the  right  of  the  patient,  the  left  hand  is  laid 
over  the  right  side  of  the  patient's  chest  so  that  the  thumb  lies  along  the 
costal  arch.  As  a  deep  breath  is  taken  the  thumb  is  pressed  upward 
toward  the  under  surface  of  the  liver.  In  addition  to  the  hypersen- 
sitiveness there  is  frequently  rigidity  of  the  upper  end  of  the  right  rectus. 
Diagnosis  of  the  Location  of  Calculi  if  Arrested  Temporarily 
or  Permanently.— ^7o;ie5   in  the  Gallbladder. — These  cither  cause  no 


340  THE   ABDOMEN. 

symptoms  or  they  are  those  of  an  acute  or  a  chronic  cholecystitis.  The 
diagnosis  of  the  former  is  taken  up  on  page  246.  That  of  the  latter  is 
made  from  the  presence  of  the  dull,  localized  pain  just  described  above, 
and  digestive  disturbances. 

Stones  in  the  Cystic  Duct. — These  cannot  be  distinguished  from 
those  of  the  gallbladder  unless  a  tumor  is  palpable  which  can  be  recog- 
nized as  due  to  a  hydrops  of  the  gallbladder  (page  297),  and  this  is  not 
frequent.  During  the  passage  of  a  stone  from  the  gallbladder  into  and 
through  the  cystic  duct  the  symptoms  are,  for  both,  those  of  biliar}^  colic. 

Stones  in  the  Common  Duct. — Pain  accompanied  by  distinct  rigors, 
irregular  fever,  jaundice  which  varies  in  degree,  and  emaciation  are 
characteristic  of  these  calculi. 

Stones  in  the  hepatic  duct  or  intrahepatic  bile-passages  cannot  be 
recognized  as  such  clinically. 


APPENDICITIS  (CHRONIC). 

The  diagnosis  of  acute  appendicitis  and  its  differentiation  from  other 
abdominal  affections  has  been  discussed  on  page  260.  There  is  a 
form  of  inflammation  of  the  appendix  whose  clinical  course  differs  some- 
what from  the  acute. 

In  this  class  of  cases  the  patient  has  had  an  acute  attack  which  was 
either  not  diagnosed  or  not  operated  upon.  From  time  to  time  attacks 
of  pain  in  the  right  iliac  region  occur  of  just  sufficient  severity  to  direct 
the  patient's  attention  to  them.  The  pain  is  usually  of  a  dull  aching 
character  and  incapacitates  the  patient  for  work  for  a  day  or  so.  It  may 
be  sharp  and  colicky  in  character,  lasting,  however,  only  a  few  minutes. 
To  the  latter  class  the  term  appendicular  colic  has  been  applied. 

To  those  cases  in  which  mild  attacks  of  dull  pain  occur  the  term 
"chronic  appendicitis"  seems  best  fitted.  Digestive  disturbances,  mu- 
cous stools,  flatulency,  and  alternating  constipation  and  diarrhea  are 
often  associated  with  the  pain.  On  palpation  a  somewhat  tender, 
elongated  mass  can  often  be  felt  in  the  appendix  region,  and  the  patient 
will  usually  refer  the  pain  to  this  point.  There  is  no  accompanying  rise 
of  temperature  or  leukocytosis.  If  adhesions  exist  between  the  adja- 
cent coils  of  intestine,  there  are  indefinite  colicky  pains  which  radiate 
from  the  ileocecal  region  toward  the  rest  of  the  abdomen.  In  palpating 
these  cases  to  confirm  the  diagnosis,  one  will  often  feel  a  cylindrical  mass 
in  the  right  ihac  region,  which  feels  like  a  chronically  inflamed  appendix. 
This  mass  can  be  followed  upward  and  downward  much  further  than  an 
appendix,  and  a  similar  mass  is  always  to  be  felt  in  the  left  iliac  region. 


CHRONIC    INTESTINAL    OBSTRUCTION.  341 

These  cylindrical  tumors  are  the  markedly  contracted  cecum  and  as- 
cending colon  on  the  right,  and  the  descending  colon  on  the  left  side, 
respectively.  The  condition  is  often  to  be  found  in  thin  individuals, 
especially  in  neurasthenics  who  suffer  from  a  chronic  mucous  colitis,  so 
frequently  accompanying  a  chronic  appendicitis. 

The  differentiation  of  these  chronic  appendicitis  cases,  in  women, 
must  be  made  from  chronic  inflammatory  conditions  of  the  adnexa,  and 
this  usually  can  be  done  by  careful  bimanual  examination ;  if  necessary 
under  an  anesthetic.  In  addition,  the  pain  of  appendicitis  is,  as  a  rule, 
higher  up  than  that  arising  from  the  adnexa.  If  much  inflammatory 
exudation  has  occurred,  it  may  be  impossible  to  differentiate  these  two 
conditions,  and  they  often  coexist. 

From  gallstones  these  cases  of  chronic  appendicitis  can  generally  be 
distinguished  by  the  fact  that  the  tenderness  in  gallstones  is  just  beneath 
the  costal  arch  unless  a  Riedel  lobe  or  hepatoptosis  is  present  (Figs.  162, 
183).  In  appendicitis  the  tenderness  and  tumor  are  in  the  right  ihac 
region,  at  McBumey's  point,  or  along  the  lower  half  of  the  right  border 
of  the  risrht  rectus. 


CHRONIC  INTESTINAL  OBSTRUCTION  (ENTEROSTENOSIS). 

Total  occlusion  of  the  intestine  means  a  complete  obstruction  to  the 
passage  of  feces,  either  through  paralysis  of  the  muscular  fibers  or  owing 
to  mechanical  causes.  The  former,  or  paralytic  ileus,  is  most  often  due 
to  septic  peritonitis,  but  may  at  times  result  from  non-septic  (neuro- 
pathic) causes. 

The  diagnosis  of  this  neuropathic  or  paralytic  form  of  intestinal  ob- 
struction can  rarely  be  made  if  due  to  non-pyogenic  causes.  If  caused  by 
septic  infection,  the  chnical  picture  is  that  of  an  acute  peritonitis.  The 
latter  has  been  discussed  in  connection  with  its  most  frecjuent  cause. 
Intestinal  obstruction  as  an  acute  process  is  taken  up  in  connection  with 
the  other  acute  abdominal  affections,  since  the  diagnosis  of  its  exis- 
tence must  be  made  in  connection  with  that  of  these  conditions,  in  the 
majority  of  cases. 

By  chronic  obstruction  of  the  intestine  (enlerostenosis)  is  meant  a 
chronic  incomplete  interference  with  the  passage  of  feces.  If,  as  not  in- 
frequently occurs,  the  occlusion  of  the  lumen  becomes  complete,  the 
clinical  picture  changes  to  that  of  acute  intestinal  obstruction  (see  page 
277). 

The  only  exception  to  the  above  statement  is  in  those  cases  of  strangu- 
lated hernia  in  which  only  a  portion  of  the  wall  has  been  caught  in  the 


342  THE    ABDOMEX. 

hernial  opening  (acute  partial  enteroceles) .  Although  the  lumen  is  not 
completely  occluded  from  an  anatomic  point  of  view,  yet  the  symptoms 
are  the  same  as  those  in  which  the  obstruction  is  complete  and  acute  in  its 
course. 

Diagnosis. — The  diagnosis  of  intestinal  stenosis  is  made  from  a 
study  of  the  histon.^,  the  symptoms,  and  the  physical  examination,  which 
conform  closely  to  the  following: 

1.  Constipation. — This  is  often  the  first  s}Tiiptom  and  may  exist  for 
a  long  time  alone.  The  patient  begins  to  notice  that  a  movement  of  the' 
bowels  is  difficult  without  a  purgative.  Xot  infrequently  the  constipa- 
tion alternates  with  attacks  of  diarrhea.  Constipation  is  an  early  symp- 
tom in  stenosis  of  the  large  but  a  ven,'  late  one  of  the  small  intestine. 

2.  Colic. — Often  this  is  the  earliest  s}Tnptom  directing  attention  to  the 
possibihty  of  a  stenosis.  The  attacks  of  pain  may  be  quite  severe  or  ver}^ 
mild.  The  pain  is  oftenest  localized  at  the  seat  of  the  stenosis,  but  may 
be  quite  difl'use.  These  paroxysms  of  pain  are  often  accompanied  by 
vomiting. 

3.  Visible  Peristalsis. — When  A'igorous  peristaltic  waves  can  be 
seen  passing  across  the  abdomen  accompanying  colicky  pains,  the 
diagnosis  of  enterostenosis  is  easily  made.  The  loops  above  the  stric- 
ture remain  distended  but  a  short  time  and  can  often  be  grasped  by  the 
hands  of  the  examiner. 

4.  Tympanites. — The  degree  of  abdominal  distention  varies  accord- 
ing to  the  completeness  of  the  stenosis.  It  may  become  so  marked  as 
to  cause  considerable  dyspnea.  Unsuccessful  eft'orts  to  pass  flatus  when 
the  abdomen  is  more  or  less  distended  should  direct  the  attention  of  a 
physician  toward  the  possibihty  of  an  enterostenosis. 

5.  Condition  of  Feces. — The  presence  of  obstinate  constipation,  al- 
ternating at  times  with  diarrhea,  has  already  been  mentioned.  If  the 
obstruction  is  low  down,  diarrhea  may  be  almost  constantly  present. 
Blood  and  pus  in  the  feces  are  often  found,  but  are  not  pathognomonic  of 
an  enterostenosis.  If  ribbon-hke  bands  of  fecal  matter  are  constantly 
passed  they  are  of  great  value  in  making  a  diagnosis. 

6.  The  examination  0}  the  abdomen  for  a  palpable  or  visible  tumor, 
and  bimanual  examination  of,  the  rectum  and  pelvis  in  general  in  both 
sexes,  should  be  a  matter  of  routine  in  every  case.  In  high-seated  rectal 
strictures  due  to  carcinomata,  proctoscopy  is  often  the  only  means  of 
making  an  early  diagnosis  (see  page  358J. 

7.  The  history  of  the  case  may  throw  some  light  on  the  probable  seat 
and  nature  of  the  process.  Progressive  loss  in  weight  accompanied  by 
symptoms  of  enterostenosis  speak  for  malignancy  (page  341). 


TUBERCULOUS    PERITOXITIS. 


34- 


8.  One  should  inquire  carefully  for  a  histor}-of  syphilis,  of  tuberculosis, 
of  pre\'ious  typhoid,  of  dysenter}',  or  of  operations  involving  the  various 
abdominal  viscera,  including  the  rectum. 

In  regard  to  the  diagnosis  of  the  seat  of  the  stenosis,  the  locahzation 
of  the  pain  and  of  the  peristalsis  may  be  of  aid,  in  addition  to  the  facts 
learned  from  abdominal  and  pelvic  examination. 


TUBERCULOUS  PERITONITIS. 

In  general,  it  may  be  said  that  tuberculous  peritonitis  occurs  in  five 
forms. 

1.  As  part    of    a    general    mihary    tuberculosis.     As  a  rule,  these 
cannot  be  diagnosed  dur- 
ing Hfe. 

2.  As  a  latent  disease 
whose  presence  is  only  dis- 
covered accidentally  at  an 
operation  for  other  condi- 
tions. 

3.  An  acute  form  with 
tenderness,  rigidity,  fever, 
etc.,  or  as  a  slower  form 
resembUng  typhoid.  Both 
of  these  have  been  de- 
scribed in  the  section  on 

acute  abdominal  affections       ^  '     ^ 

(page  250). 

4.  Those  in  which  there 
is  either  an  encapsulated 
exudate,  or  the  formation 
of  a  firm  mass  resembling 
an  abdominal  tumor. 
These  have  been  consid- 
ered in  the  section  on  abdominal  tumors  (page  307),  but  will  be  enumer- 
ated again : 

(a)  Tumors  due  to  rolling  up,  also  called  ''puckering  of  the  omen- 
tum." 

(b)  Encapsulated  exudates  (Figs.  195,  196). 

(c)  Tumors  due  to  retraction,  thickening,  and  adhesion  of  adjacent 
coils  of  intestine  (Tigs.  195,  197). 

(d)  Tumors  due  to  enlarged  mesenteric  glands  in  children. 


Fig.  206. — Area  of  Dullness  in  Extensive  Encapsulated 
Tuberculous  Peritonitis. 


344 


THE    ABDOMEN. 


5 .  The  ascitic  form  of  tuberculous  peritonitis. 

The  last  named  cases  present  the  clinical  picture  of  free  fluid  in  the 
peritoneal  cavity.  In  this  variety  the  amount  of  fluid  is  usually  not  as 
great  as  in  ascites  due  to  cirrhosis  of  the  liver  and  there  is  a  great  ten- 
dency to  early  encapsulation.  If  a  pleurisy  or  other  evidences  of  tuber- 
culosis exist,  the  diagnosis  is  easy,  as  in  the  case  shown  in  Figs.  206  and 

207.  There  is  often  a  previous 
cervical  lymph-node  infection, 
or  a  suspicious  family  history. 
In  addition  to  the  ascites, 
there  is  always  more  or  less 
tympanites,  so  that  the  disten- 
tion of  the  abdomen  is  greater 
than  the  amount  of  fluid,  as 
evidenced  by  the  dullness, 
would  lead  one  to  assume. 
There  is  often  but  httle,  if  any, 
fever  in  the  ascitic  forms. 
There  is  usually  more  or  less 
emaciation,  although  there  are 
many  exceptions.  The  pres- 
ence of  an  encapsulated  exu- 
date, in  addition  to  the  free 
fluid,  is  quite  diagnostic  of  tu- 
berculous peritonitis.  The  use 
of  tuberculin  may  clear  up  the 
diagnosis  in  doubtful  cases,  but 
it  should  be  employed  rarely. 

Differential  Diagnosis  of 
the  Ascitic  Form. — Ascites 
Due  to  Cirrhosis  oj  the  Liver. — 
An  alcoholic  history  and  the 
presence  of  a  splenic  tumor, 
as  well  as  the  more  marked  enlargement  of  the  superficial  veins,  speak 
for  cirrhosis.  The  ascitic  fluid  in  cirrhosis  is  clear,  watery,  with 
low  specific  gravity,  and  contains  only  a  trace  of  albumin,  while  in 
tuberculosis  it  contains  more  albumin  and  is  often  flocculcnt.  The 
presence  of  encapsulated  exudate  also  speaks  for  tuberculosis  as  well  as 
slight  evening  rise  of  temperature.  The  inoculation  of  guinea-pigs  with 
positive  results  or  the  use  of  tuberculin  makes  the  diagnosis  absolute. 
Carcinomatous  Afjections  Involving  the  Peritoneum. — In  this  con- 


FiG.  207. — Lateral  View  of  Abdomen  in  a  Case  of 
Tuberculous  Peritonitis. 
Same  case  as  shown  in  Fig.  206.  Note  the  promin- 
ence of  the  lower  half  of  the  abdomen  corresponding  to 
the  area  of  dullness  shown  in  Fig.  206.  Also  observe 
the  emaciation. 


Fig.  208. — Section  of  a  Coil  of  the  Ileum  from  Case  Shown  in  Fig;  206  Illus- 
trating THE  Pathology  of  Tubercular  Peritonitis. 
Note  the  yellowish  raised  miliary  tubercles  between  which  the  intestine  is  markedly 
hyperemic.  The  veiled  appearance  of  the  upper  half  is  due  to  the  fact  that  in  this  portion 
the  pseudo-membrane  has  not  been  stripped  off  from  the  underlying  tubercles.  This 
membrane  is  shown  in  a  wrinkled  or  rolled  up  manner  at  about  the  middle  of  the  picture. 


METHODS    OF    EXAMINATION.  345 

dition  the  fluid  is  often  hemorrhagic.  Emaciation  is  much  more  rapid, 
and  after  the  fluid  has  been  evacuated  tumor  masses  can  be  felt,  which 
are  harder  and  more  nodular  than  those  due  to  any  tuberculous  process. 


The  Rectum, 
methods  of  examination. 

The  methods  generally  employed  are:  (a)  Inspection;  (b)  Palpa- 
tion; (c)  Use  of  Specula. 

(a)  Inspection. — The  best  position  for  examination  of  the  anus 
and  lower  portion  of  the  rectum  is  in  one  of  three  positions.  Where  one 
is  not  provided  with  assistance,  as  in  ordinary  office  work,  the  genupec- 
toral  position  is  in  general  the  best.  For  hospital  work,  or  where  one  has 
an  assistant,  the  examination  is  best  conducted  wath  the  patient  in  the 
lithotomy  or  in  Sims'  fsemiprone)  position.  For  the  examination  of  the 
upper  portion  of  the  rectum  the  extreme  knee-chest  (genupectoral)  pos- 
ture is  most  suitable. 

(b)  Palpation. — This  should  never  be  omitted  as  a  portion  of  the 
routine  of  diagnosis  of  abdominal  conditions,  and  especially  where  symp- 
toms pointing  to  rectal  disease  are  complained  of.  The  examination  is 
best  conducted  in  either  the  recumbent,  or  knee-chest  position,  the  well 
oiled  index-finger  being  used.  A  box  of  rubber  finger-cots  or  some  heavy 
rubber  gloves  for  this  purpose  should  be  a  part  of  the  armamentarium 
of  every  physician,  since  one  can  palpate  almost  as  well  through  these 
as  with  the  unprotected  finger. 

(c)  Use  of  Specula. — There  are  many  different  kinds  of  rectal  spec- 
ula in  use,  but  a  solid  bivalve  speculum  which  tapers  and  opens  one  side 
is  the  best.  The  examination  will  be  greatly  aided  by  the  use  of  either 
an  electric  head-lamp  or  of  a  head-mirror  with  reflected  light. 

For  the  examination  of  the  upper  portion  of  the  rectum  the  use  of  a 
proctoscope  is  indispensable. 

A  speculum  should  always  be  well  oiled  before  being  introduced  and 
be  slightly  warm.  The  bivalve  specula  must  never  be  rotated  after 
being  introduced,  but  preferably  introduced  a  second  time  if  it  is  de- 
sirable to  examine  a  different  portion  of  the  rectum. 

For  the  demonstration  of  affections  of  the  lower  half  of  the  rectum 
when  the  patient  is  anesthetized,  the  Sims  or  Simon  vaginal  specula  are 
very  valuable.  The  use  of  other  instruments  may  be  necessary  in  mak- 
ing a  diagnosis  of  special  affections,  such  as  that  of  probes  in  anal  fistula 
or  of  graduated  bougies  to  determine  the  caliber  of  strictures.  The 
latter  are  best  passed  with  the  aid  of  the  proctoscope. 


346  THE    ABDOMEN. 

History. — Before  beginning  the  examination  every  patient's  history- 
should  be  taken  as  accurately  as  possible,  as  follows : 

1.  Pain. — What  is  its  character?  Is  it  sharp,  lancinating,  burning, 
throbbing,  or  only  a  sensation  of  pressure  ? 

Relation  to  bowel  movements  ?  Is  the  pain  intermittent  ?  is  it  in- 
dependent of  the  movements?  does  it  precede,  accompany,  or  follow 
them  ?  How  long  does  the  pain  last  ?  Is  it  felt  in  the  rectum  or  around 
it,  or  does  it  radiate  ? 

2.  Bowel  Movements. — Does  constipation  or  diarrhea  exist?  Is  the 
stool  formed  or  loose  ?  is  it  ribbon-hke  ?  is  the  odor  marked  ? 

3.  Escape  of  Blood,  Pus,  etc. — Does  mucus,  pus,  or  bloody  discharge 
exist  ?  How  often  does  this  occur,  in  what  quantity,  and  does  it  accom- 
pany defecation  or  occur  independently  ?  Is  the  blood  black  and  tarry, 
is  it  fresh  and  red,  or  are  the  feces  merely  streaked  with  blood  ? 

4.  General  Condition. — ^ Whether  any  organic  disease  of  the  heart, 
liver,  or  kidneys  exists  ?  Has  the  patient  a  family  or  personal  history  of 
carcinoma,  tuberculosis,  syphihs,  or  gonorrhea?  Does  any  other  pelvic 
condition  exist? 

5.  Character  of  Protrusion,  if  Any. — Does  it  bleed  ?  Can  it  be  readily 
reduced  ?     Does  it  protrude  during  defecation,  or  at  regular  periods  ? 


CONGENITAL  MALFORMATIONS. 

There  are  four  chief  forms  of  this  condition : 

(a)  Atresia  Ani  (No.  i  of  Fig.  209). — The  anus  is  entirely  absent 
or  only  represented  by  a  slight  depression.  The  bowel  ends  blindly 
and  may  be  separated  from  the  skin  by  a  thin  membrane.  This  is  the 
most  frequent  form. 

(b)  Atresia  Ani  et  Recti  (No.  2  of  Fig.  209).— The  anus  and  rectum 
are  not  developed.  The  colon  ends  as  a  blind  sac  at  the  level  of  the 
sacral  promontory.     There  is  no  indication  externally  of  an  anus. 

(c)  Atresia  Recti  (No.  3  of  Fig.  209). — The  rectum  is  formed  down 
to  the  level  of  the  sphincters.  The  anal  portion  is  normally  formed. 
Both,  however,  end  blindly  and  may  be  separated  only  by  a  membrane 
or  by  a  septum  of  connective. tissue  which  is  i  to  i^  inches  (3  to  4  cm.) 
thick. 

(d)  Abnormal  Opening  of  the  Rectum  (No.  4  of  Fig.  209). — 
The  anus  is  closed  and  the  rectum  opens  into  either  the  vagina  or  into 
the  bladder,  or  even  into  the  urethra. 

The  diagnosis  of  which  one  of  these  four  conditions  is  present,  can 
seldom  be  made  before  operation.     As  a  result  of  retention  of  meconium 


INJURIES    OF   THE    RECTUM.  347 

the  abdomen  becomes  greatly  distended  and  vomiting  follows.  The  lat- 
ter may  be  feculent  at  an  early  period  or  only  appear  late,  if  a  peritonitis 
has  begun.  In  every  new-bom  child  which  does  not  pass  meconium 
within  six  to  twenty-four  hours  after  birth,  the  anus  should  be  examined. 
A  number  of  these  cases  have  been  operated  upon  successfully  in  which 
such  an  early  diagnosis  was  made. 


Fig.  2og. — Various  Forms  of  Congenital  Malformations  of  Anus.     (See  page  346.) 
B  Bladder;  R,  rectum;  A,  primitive  anus.     In  figure  4  the  white  arrow  shows  the  communication  between  the 

bladder  and  rectum  (Esmarch). 


INJURIES  OF  THE  RECTUM. 

These  may  be  divided  into  ruptures  and  penetrating  wounds. 

In  the  former  class  belong  {a)  those  which  accompany  a  fracture  of 
the  pelvis,  {h)  those  following  violent  straining  during  defecation.  This 
is  more  apt  to  occur  in  women  who  have  previously  had  a  rectoccle. 
(c)  Extension  into  the  rectum  of  perineal  lacerations  during  parturition. 

Penetrating  wounds  follow  stab  or  bullet  wounds,  falls  upon  a 
picket  fence  or  other  sharp  object,  careless  introduction  of  enema  points 
or  of  bougies. 


348  THE   ABDOMEN. 

In  the  diagnosis  of  an  injury  to  the  rectum  the  important  points  are 
the  histor}',  the  accompanying  internal  or  external  signs  of  injur}-,  and 
the  escape  of  blood  or  of  intestinal  coils  through  the  anus  or  vagina. 

Later  on  there  are  the  signs  of  infection  with  the  formation  of  an 
ischiorectal  abscess  or  of  a  more  diffuse  perirectal  phlegmon.  If  the 
tear  passes  through  the  peritoneal  attachment  the  signs  of  a  septic 
peritonitis  appear  within  a  few  hours  after  tlie  injury. 

The  hemorrhage  from  a  wound  or  tear  of  the  rectum  may  be  a  con- 
cealed one,  the  blood  accumulating  in  the  rectum  and  pelvic  colon  while 
the  patient  shows  signs  of  internal  hemorrhage,  such  as  pallor,  s}mcope, 
rapid  empty  pulse,  restlessness,  etc. 

In  addition  to  the  above  mentioned  symptoms,  a  digital  examination 
and  the  use  of  a  speculum  are  necessary  to  confirm  the  diagnosis. 


FOREIGN  BODIES  IN  THE  RECTUM. 
These  may  be  divided  into  three  classes : 

(a)  Those  which  have  formed  within  the  body,  e.  g.,  gallstones, 
enteroHths,  impacted  feces.  The  last  named  may  attain  the  size  of  a 
child's  head. 

(b)  Those  which  have  been  swallowed,  e.  g.,  fish-bones,  peach-stones, 
rings,  all  sorts  of  objects  swallowed  by  the  insane,  such  as  forks,  spoons, 
nails,  balls  of  hair,  etc. 

(c)  Those  which  are  introduced  through  the  anus,  either  accidentally 
or  with  some  object  in  view,  such  as  aiding  a  bowel  movement  or  in  the 
insane,  or  in  sexual  perverts. 

The  diagnosis  may  be  made  in  many  of  the  cases  if  attention  has 
been  directed  to  the  rectum  through  one  of  the  following  symptoms : 

(a)  The  occurrence  of  tenesmus  accompanied  by  the  passage  of 
blood  or  mucus  in  elderly  people,  who  have  suffered  from  obstinate  con- 
stipation. In  others  the  first  signs  may  be  inability  to  urinate  through 
pressure  on  the  urethra. 

(b)  The  occurrence  of  evidences  of  an  infection  of  the  perirectal 
tissues. 

(c)  The  history  of  swallowing  some  foreign  body  or  its  introduction 
through  the  anus. 

One  should  never  neglect  under  the  above  conditions  to  make  a  thor- 
ough digital  examination  and  to  combine  with  it,  the  use  of  the  speculum. 


INFLAMMATORY   PROCESSES    AXD    THEIR   RESULTS. 


549 


INFLAMMATORY  PROCESSES  AND  THEIR  RESULTS. 

These  include :  (a)  Pruritus  ani,  (b)  proctitis,  (c)  perirectal  infection 
(phlegmons  and  ischiorectal  abscesses),  (d)  fistulas,  (e)  ulcerations,  in- 
cluding anal  fissure. 

Pruritus  Ani. — This  is  often  associated  with  chronic  constipation, 
hemorrhoids,  etc.,  and  in  some  cases,  no  cause  can  be  found.  It  causes 
an  intense  itching,  especially  at  night.  The  skin  of  the  anal  region 
becomes  of  a  silvery  white  color  and  is  greatly  thickened.  The  disease 
often  appears  periodically 
with  each  menstruation  or 
pregnancy. 

Proctitis. — This  occurs 
in  an  acute  and  chronic 
form. 

In  acute  proctitis  there  is 
(a)  pain  in  the  rectum  radi- 
ating to  the  coccyx,  peri- 
neum, or  thighs,  (b)  Con- 
stant straining  and  the  pass- 
age of  mucus  and  blood. 
There  is  intense  pruritus 
ani.  (c)  Constant  desire  to 
urinate.  There  may  be  re- 
tention of  urine,  (d)  Both 
external  and  internal 
sphincters  are  found  mark- 
edly contracted  when  the 
finger  is  introduced.  The 
rectum  feels  hot  and  is  very 

tender,  and  if  a  speculum  can  be  introduced  the  mucosa  is  seen  to  be 
greatly  congested  and  swollen. 

Chronic  Proctitis. — The  most  common  causes  in  children  are  the 
presence  of  polypi  or  of  pin- worms;  rarely  it  is  due  to  a  congenital 
syphihs.  In  adults  it  either  follows  an  acute  attack  or  is  chronic  from 
the  beginning,  and  then  is  most  frequently  due  to  syphilis  or  gonorrhea, 
less  often  to  tuberculosis  or  a  prolapse. 

There  are  two  forms,  a  hypertrophic,  in  which  ulcerations  and  papil- 
lomatous excrescences  occur  on  the  mucosa,  and  an  atro])hic  or  stenosing 
form.  The  two  may  be  combined  in  some  cases.  In  the  latter,  which 
is  most  often  due  to  syphihs,  there  is  either  circumscribed  or  more  diffuse 


Fig.  2IO. — ^Larked  Elephantiasis  of  the  External  Fe- 
male   Genitalia    and   Syphilitic    Condylomata   of 

RECTUil. 

I,  Elephantiasis  of  the  clitoris;  2,  elephantiasis  of  left 
labium  majus:  3,  similar  condition  of  right  labium  minus;  4, 
syphiUtic  condylomata  of  rectum. 


350  THE    ABDOMEN. 

infiltration  of  the  entire  thickness  of  the  rectal  wall  and  of  the  perirectal 
tissues,  resulting  in  the  formation  of  strictures  (see  page  357). 

The  diagnosis  of  the  hypertrophic  form  may  be  made  if  there  is  a" 
history  of  a  preceding  acute  attack  followed  by  frequent  bowel  move- 
ments, consisting  principally  of  pus  and  mucus.  This  condition  may 
alternate  with  constipation.  In  some  cases  there  is  but  little  tenesmus 
or  pain,  while  in  others  it  is  very  marked. 

Perirectal  abscesses  and  fistulas  very  often  complicate  the  cHnical 
picture,  especially  if  the  pus  cannot  readily  escape  through  the  anus. 

There  is  in  many  cases  the  history  of  a  gonorrhea  or  the  presence  of 
fissures,  hemorrhoids,  or  fistula.  Examination  with  the  finger  or  specu- 
lum, and  in  some  cases  through  the  proctoscope,  will  confirm  the  diag- 
nosis in  the  hypertrophic  form. 

From  carcinoma,  the  hypertrophic  form  can  be  differentiated  by  the 
fact  that  there  is  soft  mucosa  between  the  individual  polypoid  elevations. 
There  is  also  an  absence  of  the  marked  induration  of  cancer. 

In  many  doubtful  cases  a  microscopic  examination  should  be  made. 

Multiple  polypi  in  children  and  young  adults  may  resemble  it,  but 
these  are  usually  larger  and  there  is  no  ulceration  between  them.  In 
some  cases,  if  ulcerations  exist,  it  is  impossible  to  make  a  distinction. 

Perirectal  Infection. 

Diffuse  Perirectal  Phlegmon. — This  may  follow  insufficient 
drainage  of  an  ischiorectal  abscess  or  arise  through  extension  of  sup- 
puration from  neighboring  structures  like  the  prostate  or  uterus. 

]Most  frequently  it  follows  some  operation  upon  the  rectum  in  which 
infection  has  occurred. 

The  diagnosis  can  be  made  from  the  local  signs  of  infection  in  the 
tissues  around  the  anus  and  those  of  a  general  infection.  These  are 
marked  infiltration,  redness,  pain,  and  rise  of  local  and  general  tem- 
perature. 

In  a  case  recently  seen  the  most  marked  symptom  was  a  retention  of 
urine  through  pressure  on  the  urethra.  The  infiltration  may  extend 
over  the  perineum  toward  the  scrotum  and  resemble  an  extravasation 
of  urine,  but  in  the  latter  there  is  more  involvement  of  the  scrotum,  while 
in  perirectal  phlegmon  the  chief  external  swelHng  is  around  the  anus. 
Unless  the  condition  is  reheved  the  septic  infiltration  spreads  and  signs  of 
severe  general  intoxication  appear. 

Circumscribed  Suppuration. — This  occurs  in  other  locations  than 
the  ischiorectal  fossa,  and  it  is  often  of  importance  to  recognize  the  exact 
location  of  a  focus. 


INFLAMMATORY   PROCESSES    AND    THEIR    RESULTS. 


OD 


These  may  be  divided  (Fig.  211)  into: 

I.  Intrasphincteric  abscesses,  i.  e.,  inside  of  the  sphincter  ani. 
(a)  Subcutaneous. 


Fig.  211. — Various  Forms  of  Ischiorectal  Abscesses  and  Fistul^e. 
Fig.  I,  Locations  of  ischiorectal  abscesses:  IR,  Ischiorectal  fossa;  £,  external  sphincter;  5,  internal 
sphincter;  B,  ramus  of  ischium;  U,  space  above  levator  ani  muscle;  JV,  mucous  membrane  of  rectum.  The 
same  figures  apply  to  the  lower  illustration,  i,  Most  frequent  form  of  ischiorectal  abscess,  pushing  skin  of  anal 
region  outward;  2,  submucous  abscess  above  the  internal  sphincter;  3,  abscess  situated  above  levator  ani 
muscle  in  pehdc  connective  tissue;  4,  subcutaneous  extrasphincteric  abscess.  Fig.  2,  On  the  left-hand  side  is 
seen  a  complete  internal  and  external  fistula.  On  the  right  side  is  seen  a  fistula  situated  beneath  the  mucous 
membrane  and  burrowing  deeply  into  the  upper  portion  of  the  ischiorectal  fossa.  IE  of  this  lower  illustration 
represents  an  incomplete  fistula,  having  only  an  external  opening. 


(b)  Submucous. 

(c)  Both  of  above  combined. 

2.  Extrasphincteric  abscesses  (ischiorectal). 

3.  Abscesses  of  the  superior  pelvirectal  space  (deep-seated). 


352  THE    ABDOMEN. 

Diagnosis  of  Intrasphincteric  Abscesses. ^ — The  first  sign  is  usu- 
ally pain  referred  to  the  anus,  accompanied  by  tenderness  on  pressure. 
Examination  with  the  finger  will  reveal  in  the  first  variety  (subcuta- 
neous) an  area  of  quite  circumscribed  tender  induration  just  beneath 
the  skin  and  close  to  the  anal  margin.  In  the  submucous  variety  the 
finger  must  be  inserted  through  the  anus.  One  then  feels  a  boggy,, 
tender  swelling  just  above  the  anal  margin  beneath  the  mucosa.  When 
these  two  are  combined  (submucocutaneous)  the  external  indurated 
area  passes  directly  over  into  the  one  situated  within  the  anal  margin. 

The  local  symptoms  are  accompanied  by  fever,  constipation,  malaise, 
etc. 

In  many  cases  the  abscesses  have  already  ruptured  spontaneously 
when  the  patient  is  examined.  One  will  then  find  an  external  fistulous 
opening  which  does  not  lead  alongside  the  rectum,  as  do  the  true  anal 
fistulae.  In  case  a  submucous  abscess  has  burst,  the  opening  will  be 
found  just  above  the  external  sphincter  and  the  cavity  lies  beneath  the 
mucosa  quite  superficially. 

Extrasphincteric  Abscesses. — These  are  the  varieties  ordinarily 
spoken  of  as  ischiorectal.  They  may  follow  any  of  the  intrasphincteric 
forms  or  arise  in  the  deeper  parts  of  the  ischiorectal  fossa. 

If  the  infection  begins  near  the  skin,  the  symptoms  of  suppuration 
are  more  marked  than  if  it  begins  deeply. 

There  is  pain  referred  to  the  ischiorectal  region  in  the  superficial 
form,  accompanied  by  tenderness  on  pressure.  The  skin  over  the 
ischiorectal  region  becomes  red,  edematous,  and  hot,  and  there  are  soon 
evidences  of  fluctuation. 

Frequently  the  abscess  breaks  spontaneously. 

In  the  deeper  variety  the  symptoms  are  often  quite  obscure  at  first. 
There  is  deep-seated  pain  accompanied  by  signs  of  general  infection, 
such  as  high  fever,  prostration,  rapid  pulse,  etc. 

If  the  finger  is  pressed  upon  the  ischiorectal  region  either  from  with- 
out or  through  the  rectal  wall,  there  is  considerable  tenderness.  The 
signs  of  infiltration  of  the  skin  of  the  ischiorectal  region  appear  at  a  later 
period. 

If  the  pus  is  not  evacuated  an  abscess  of  the  upper  pelvirectal  space 
may  result,  or  the  pus  may  travel  around  the  rectum  to  the  opposite 
ischiorectal  region.  The  abscess  may  open  spontaneously  at  some  dis- 
tance from  the  anal  margin. 

Abscesses  of  the  Superior  Rectal  Space  (Fig.  211). — These  may 
result  from  suppuration  in  the  prostate,  in  the  periuterine  tissue,  in 
the  rectum  and  bones  of  the  pelvis.     Abscesses  of  this  space  may  also  be 


INFLAMMATORY    PROCESSES    AND    THEIR   RESULTS.  353 

the  result  of  neglected  ischiorectal  abscesses,  or,  on  the  other  hand, 
abscesses  of  this  space  can  perforate  into  the  ischiorectal  fossa  (Fig.  211). 
The  diagnosis  of  these  abscesses  is  often  very  difficult.  There  is 
deep-seated  pain,  fever,  and  signs  of  general  septic  intoxication.  Locally 
there  is,  in  addition  to  the  pain,  often  retention  of  urine,  constipation, 
and  infiltration  of  the  tissues  around  the  rectum.  Through  rectal  or 
vaginal  palpation  one  can  distinguish  the  point  of  greatest  tenderness. 
The  differentiation  of  this  variety  from  abscesses  of  the  prostate,  pelvic 
abscess,  or  bone  suppuration  is  often  very  difficult,  and  at  times  impos- 
sible, except  from  the  history  and  the  fact  that  the  tenderness  and  in- 
duration in  this  form  are  most  marked  in  close  proximity  to  the  rectum. 

Fistula  in  And. 

The  majority  of  these  follow  an  infection  of  the  perirectal  tissues  with 
abscess  formation,  whether  due  to  the  ordinary  pus  organism  or  the 
tubercle  bacillus. 

The  common  varieties  are  sho\\Ti  in  Fig.  211.     They  are: 

1.  Complete.  The  external  opening  is  located  either  close  to  the 
anus  or  at  some  distance  away  in  the  gluteal  or  perineal  regions.  The 
internal  opening  is  usually  posteriorly,  at  the  junction  of  the  two  sphinc- 
ters, seldomi  above  it. 

2.  Incomplete  internal.  There  is  only  an  inner  opening  leading 
into  a  blind  sinus.     These  are  infrequent. 

3.  Incomplete  external.  The  sinus  in  the  majority  of  cases  lies  just 
beneath  the  skin,  and  it  is  formed  from  one  of  the  intrasphincteric 
variety  of  abscesses  described  on  page  352.  There  are,  however,  a 
number  of  these  which  are  the  result  of  a  complete  fistula  in  which  the 
inner  opening  has  closed. 

The  rarer  varieties  of  fistulae  are : 

(a)  Complete  internal  (both  openings  internal). 

(h)  Complete  external  (both  openings  external  to  the  rectum). 

(c)  Rectovaginal  and  rectovesical. 

(d)  Horseshoe.  (The  sinus  runs  around  the  rectum  like  a  horse- 
shoe. There  are  often  many -external  openings  and  branch  sinuses 
running  in  all  directions.) 

The  diagnosis  of  a  fistula  is  not  difficult  if  an  external  opening  exists 
from  which  pus  is  discharged.  This  may  cease  for  a  time  but  reopen 
again. 

The  incomplete  internal  fistulcC  cause  some  pain  on  defecation  and 
the  discharge  of  pus. 

In  order  to  demonstrate  the  course  of  a  fistula  a  flexible  probe  should 
23 


354  THE    ABDOMEN. 

be  used,  aided  by  the  finger  inserted  into  the  rectum.  One  should  never 
use  any  force  in  passing  a  probe  along  the  tract. 

In  the  majority  of  fistulae  the  inner  opening  is  located  posteriorly, 
about  half  an  inch  above  the  anus,  and  can  be  felt  as  a  depression,  or 
more  often  a  slight  elevation.  The  opening  may  in  rare  instances  be  at 
any  point.  At  times  the  injection  of  methylene-blue  into  the  external 
opening  or  the  injection  of  bismuth  followed  by  the  taking  of  an  x-ray 
picture  (Beck)  will  aid  in  finding  the  inner  one. 

The  presence  of  openings  on  both  sides  of  the  anus  indicates  a  horse- 
shoe fistula. 

In  incomplete  internal  fistula  one  feels  an  induration  on  inserting 
the  finger  into  the  rectum  and  a  depression  where  the  fistulous  opening  is 
located.  For  the  diagnosis  of  these,  the  use  of  a  speculum  is  usually 
necessary.  Tuberculous  fistulae  usually  accompany  the  same  disease 
elsewhere,  and  the  external  opening  is  large,  hned  by  pale,  flabby  granu- 
lations, and  the  edges  are  bluish  and  often  undermined.  Non-tuber- 
culous fistulae  may,  however,  exist  in  phthisical  patients. 

Anal  Fissure. 

The  most  prominent  symptom  of  this  condition  is  pain  of  a  severe 
character  on  defecation.  On  account  of  this  pain  there  is  marked  con- 
stipation. The  other  symptoms  are  intense  pruritus  and  reflex  distur- 
bances, such  as  increased  desire  to  urinate.  The  diagnosis  can  be  made 
from  the  severity  of  the  pain  on  defecation  and  from  the  local  examination. 
The  latter  will  often  show  an  acute  inflamed  external  hemorrhoid,  the 
"  sentinel  pile,"  on  the  inner  side  of  which  the  painful  ulcer  or  fissure  can 
be  seen. 

In  some  cases  digital  examination  is  necessary.  The  sphincter  will 
be  found  tightly  contracted  and  the  finger  or  probe  can  be  made  to  touch 
every  point  until  the  painful  spot  is  found.  The  latter  is  slit-like  and 
has  somewhat  hard  edges. 

Non-malignant  Ulceration. 

These  may  be  (a)  traumatic,  (b)  catarrhal,  following  acute  or  chronic 
proctitis,  (c)  dysenteric,  (d)  gonorrheal,  (e)  tuberculous,  (/)  syphilitic,  (g) 
varicose. 

The  chief  symptoms  of  all  of  these  are  the  same  as  those  of  a  chronic 
proctitis,  viz.,  the  discharge  of  pus  and  blood  accompanied  by  diarrhea. 
The  evacuations  are  usually  accompanied  by  tenesmus  and  hemorrhage 
in  a  greater  or  less  degree. 

The  diagnosis  can  be  made  (a)  by  taking  an  accurate  history;  (b) 


HEMORRHOIDS.  355 

by  a  careful  examination  of  the  rest  of  the  body  for  evidences  of  syphihs, 
tuberculosis,  etc.;  (c)  by  a  local  examination.  In  almost  all  varieties 
there  is  marked  contraction  of  the  sphincter.  In  syphilis  ulceration  is 
most  frequent  in  the  tertiary  stage,  and  especially  marked  in  the  lower 
part  of  the  rectum.  The  same  is  true  for  gonorrhea.  Both  cause 
marked  infiltration  of  the  rectal  walls  and  multiple  ulcerations. 

Tuberculous  ulcers  have  an  irregular  shape,  are  of  large  size,  have 
undermined  edges,  and  the  base  is  not  indurated.  It  is  most  frequent 
around  the  anal  margin  or  close  to  the  external  sphincter  and  is  often 
accompanied  by  a  fistula. 

In  some  cases  of  rectal  ulceration  an  exact  diagnosis  of  its  nature  is 
very  difficult,  if  not  impossible. 


HEMORRHOIDS. 

These  are  usually  divided  into  : 

(a)  External  (covered  by  skin). 

(b)  Internal  (covered  by  mucous  membrane). 

(c)  Combination  piles  (a  and  b  combined). 

It  is  important  from  a  diagnostic  point  of  view  to  distinguish : 

(a)  Those  which  are  secondary  to  pregnancy,  diseases  of  the  heart  or 
liver,  uterus  and  adnexa,  or  to  tumors  of  the  rectum  or  prostate. 

(b)  Those  which  are  primary. 

The  diagnosis  of  hemorrhoids  can  be  readily  made  in  the  majority  of 
cases.  In  the  uncomplicated  cases  the  patients  complain  of  a  feeling 
of  weight,  of  an  itching  or  burning  sensation  and  occasional  tenes- 
mus. There  is  but  little  pain  unless  an  ulcer  or  a  fissure  coexists. 
If  internal  hemorrhoids  prolapse  there  is  some  pain  until  they  are 
returned. 

In  many  cases  the  patient's  attention  is  first  directed  to  the  rectum  on 
account  of  frequent  bleeding.  The  latter  may  be  quite  profuse  or  be 
small  in  amount  and  occur  with  every  bowel  movement,  so  that  the 
patient  becomes  quite  weak  and  anemic. 

External  hemorrhoids  are  usually  visible  upon  simply  exposing  the 
anal  region.  Internal  hemorrhoids  are  seldom  to  be  seen  unless  the 
patient  strains  or  they  protrude  during  defecation  or  they  have  become 
inflamed. 

External  hemorrhoids  are  either  soft,  fleshy,  bluish  masses,  or  firm 
skin  tags  which  cannot  be  reduced.  If  of  the  softer  variety  they  can  be 
caused  to  disappear  by  pressure,  but  the  mass  rapidly  reappears.  In- 
ternal hemorrhoids  are   covered   with  dark  red,   swollen   membrane. 


356  THE    ABDOMEN. 

They  may  be  single  or  multiple,  the  latter  forming  a  fringe  around  the 
anal  margin  when  they  are  protruded. 

Allingham  distinguishes  three  kinds  of  the  internal  variety — capil- 
lary, venous,  and  arterial.  The  first  named  are  deep  red,  bleed  readily 
and  profusely.  The  venous  are  quite  large,  firm,  of  a  pale  hvid  color, 
do  not  bleed  much,  and  readily  protrude.  The  arterial  are  firm,  large, 
bleed  readily,  and  the  blood  spurts  as  from  an  artery. 

Of  these,  the  capillary  and  arterial  are  rare,  the  venous  being  the 
common  variety. 

The  complications  of  hemorrhoids  are  thrombosis,  inflammation, 
strangulation,  and  sloughing. 

Thrombosis  usually  occurs  in  the  external  variety.  The  hemor- 
rhoid becomes  very  hard  and  greatly  enlarged.  It  causes  the  patient 
great  discomfort  and  frequent  attacks  of  tenesmus. 

Inflammation  most  often  complicates  the  internal  variety.  The 
hemorrhoids  become  very  painful  and  firm  and  remain  protruded. 

Sloughing  and  strangulation  are  rare  complications. 


PROLAPSE. 

This  condition  of  protrusion  of  the  rectum  is  quite  frequent  in  chil- 
dren and  in  old  people,  but  may  occur  at  any  age.  It  is  more  frequent 
in  women  than  in  men,  associated  in  the  former  with  general  enteroptosis 
and  uterine  prolapse.  The  most  common  form  is  a  prolapse  of  the 
mucous  membrane  only.  This  is  called  a  partial  prolapse  and  usually 
occurs  in  children. 

A  complete  prolapse  of  all  the  coats  (Fig.  212)  occurs  less  fre- 
quently than  the  partial  form.     It  is  the  usual  form  in  adults. 

The  diagnosis  of  prolapse  is  easy.  The  protrusion  embraces  the 
entire  circumference  of  the  bowel  and  is  of  reddish  color  with  a  depression 
in  the  center.  The  partial  prolapse  of  children  can  be  readily  reduced 
and  protrudes  only  when  the  child  strains  as  at  a  stool,  etc.  The  com- 
plete prolapse  remains  out  most  of  the  time  and  the  mucous  membrane 
becomes  very  sensitive  and  bleeds  easily.  The  condition  can  be  dis- 
tinguished from  hemorrhoids. by  the  fact  that  in  the  latter  the  protrusion 
is  irregular  and  one  can  feel  the  separate,  soft,  dark  blue,  hemorrhoidal 
tumors.  Epithelioma  of  the  anus  feels  quite  hard  and  cannot  be  reduced. 
The  surface  is  often  ulcerated  or  covered  with  cauhflower  excrescences. 
An  intussusception,  when  it  protrudes,  may  resemble  a  prolapse.  The 
finger  when  passed  around  the  edge  of  the  protrusion  will  find  a  groove 
or  sulcus  between  the  skin  and  the  mass,  while  in  prolapse  this  is  absent. 


STRICTURES    OF   THE    RECTUM. 


357 


STRICTURES  OF  THE  RECTUM. 

These  may  be  divided  into  annular  and  tubular,  according  to  whether 
the  stenosis  is  circumscribed  or  more  diffuse.  For  diagnostic  purposes  a 
good  division  is  into : 

I.  Extrinsic,  caused  by  pressure  from  without,  as  from  cancer  of  the 
prostate  or  rectum  or  from  pelvic  exudates,  or  tumors  of  the  bones  of  the 
pelvis. 


iitni 


Fig.  212. — CoMPLETK  Prolapse  of  the  Rectum. 
L,  Depression  corresponding  to  lumen  of  rectum;    PM,  prolapsed  mucous  membrane  of  rectum. 

2.  Intrinsic,  due  most  often  either  to  (a)  syphihs,  (b)  carcinoma, 
or  (c)  gonorrhea. 

Congenital,  traumatic,  dysenteric,  and  tuberculous  strictures  are  very 
rare  in  their  occurrence  and  their  existence  is  denied  by  many  experienced 
proctologists. 

The  diagnosis  of  the  existence  of  a  stricture  is  not  difficult  from  a 
consideration  of  the  symptoms  and  local  iindings.  As  to  the  etiology  of 
any  particular  case,  the  question  is  a  more  difficult  one.  The  most 
prominent  symptom  is  constipation,  which  may  increase  to  complete 
stenosis,  followed  by  symptoms  of  intestinal  obstruction.  In  some  cases 
the  first  symptom  is  a  persistent  diarrhea,  accompanied  by  marked 


358  THE   ABDOMEN. 

tenesmus.  In  the  non-malignant  cases  there  is  a  frequent  discharge  of 
pus  and  mucus.  Pain  is  not  a  prominent  symptom,  but  in  the  mahgnant 
cases  there  may  be  marked  radiation  of  pain  along  the  sciatic  nerves. 

The  local  examination  should  be  made  first  with  the  finger;  then, 
if  it  is  necessary,  the  speculum  or  proctoscope  may  be  used.  The  syste- 
matic use  of  the  latter  is  to  be  warmly  recommended  where  symptoms  of 
stenosis  exist.  It  should  be  combined  with  the  examination  of  the  lower 
rectum  with  the  finger  and  speculum.  One  can  make  an  early  diagnosis 
of  a  high-seated  stricture  by  this  means  better  than  by  any  other. 

In  making  a  diagnosis  of  the  cause  of  the  stricture  the  history  is  of 
great  value.  Syphilis  is  the  cause  of  the  majority  of  non-malignant 
strictures,  and  careful  inquiry  must  be  made  as  to  the  possibility  of  an 
acquired  or  congenital  syphilis.  Search  should  be  made  for  evidence  of 
the  disease. 

Gonorrheal  stricture  is  more  frequent  in  women  and  can  only  be 
diagnosed  from  the  history  and  the  absence  of  syphilis.  Stricture  from 
extrinsic  causes  can  be  diagnosed  by  the  examination  of  the  pelvis,  the 
uterus,  the  prostate,  etc. 

To  differentiate  a  non-malignant  from  a  malignant  stricture  the 
following  table  from  Ball  will  be  of  aid: 

DIFFERENTIAL   DIAGNOSIS   BETWEEN   NON-MALIGNANT  AND  MALIG- 
NANT STRICTURE.— (Ba//.) 
Non-malignant  Stricture.  Mai.ignant  Stricture. 

1.  Generally  a  disease  of  adult  life.  i.  Generally  a  disease  of  old  age. 

2.  Essentially  chronic,  and  not  implicating       2.  Progress  comparatively  rapid  and  general 

the  system  for  a  long  time.  cachexia  soon  produced. 

3.  The  orifice  of  the  stricture  feels  like  a       3.  Masses  of  new  growth  are  to  be  felt 

hard  ridge  in  the  tissues  of  the  bowel.  either    as    flat    plates     beneath  the 

Polypoid    growths,    if    present,    are  mucous  membrane  and  the  muscular 

felt  to  be  attached  to  the  mucous  tunic,  or  as  distinct  tumors  encroach- 

membrane.  ing  on  the  lumen  of  the  bowel. 

4.  Ulceration  of  the  mucous  membrane  may  4.  Ulceration,  when    present,  is    evidently 

be  present,  but  without  any  great  in-  the  result  of  breaking  down  of  the 

duration  of  the  edges.  neoplasm;      the     edges     are     much 

thickened  and  infiltrated. 

5.  The  entire  circumference  of  the  bowel  is       5.  Generally,  one  portion  of  the  circum- 

constricted  unless  the  stricture  is  val-  ference  is  more  obviously  involved, 

vular. 

6.  Pain,  throughout  the  whole  course,  in       6.  In    the    advanced    stages    pain    is    fre- 

direct   proportion   to   the   fecal   ob-  quently  referred  to  the  sensory  dis- 

struction,   and   complained   of  only  tribution  of  some  of  the  branches  of 

during  defecation.  the  sacral  plexus,  due  to  direct   im- 

plication of  their  trunks. 

7.  Glands  not  involved.  7.  The  sacral  lymphatic  glands  can  some- 

times be  felt  through  the  rectum  to 
be  enlarged  and  hard.  Inguinal 
glands  hard. 


NEOPLASMS    OF   THE    RECTUM.  359 

NEOPLASMS  OF  THE  RECTUM. 

Polyps. — These  are  most  frequently  found  in  children.  They  are 
adenomata,  and  usually  single,  with  a  narrow,  long  pedicle.  Less  often 
they  are  multiple  and  sessile. 

They  may  exist  for  years  without  causing  any  symptoms.  It  is  only 
after  they  begin  to  bleed  or  are  caught  within  the  anal  orifice  that  they 
give  rise  to  symptoms.  They  may  be  accompanied  by  the  signs  of 
proctitis  (page  349). 

Whenever  a  child  strains  at  stool,  without  showing  evidences  of  a 
prolapse,  and  passes  blood  frequently,  the  examining  physician  should 
insert  the  little  finger  into  the  rectum  and  examine  the  entire  circumfer- 


FiG.  213. — Non-malignant  Papilloma  of  the  Anus  ("  International  Text-Book  of  Surgery  "). 

ence  of  mucosa.  A  polyp  can  be  readily  recognized  as  a  soft,  cherry-like, 
very  movable  tumor  attached  to  the  mucosa  by  a  narrow  pedicle. 
When  they  protrude  through  the  anus,  their  mobihty  and  the  presence 
of  a  pedicle  render  differentiation  from  a  hemorrhoid  easy.  The  attach- 
ment of  the  pedicle  may  be  high  up  in  the  rectum  or  even  in  the  sigmoid. 

In  prolapse  the  protrusion  involves  the  entire  circumference  of  the 
anus,  has  no  pedicle,  and  a  distinct  tumor  cannot  be  felt. 

Broad,  sessile  polyps  occurring  in  older  persons  have  a  tendency  to 
become  malignant. 

Carcinoma  of  the  Rectum. — This  is  predominantly  a  disease  of  old 
age,  but  may  occur  between  fifteen  and  thirty.  There  are  two  forms — the 
epithelioma  of  the  anus  and  the  adenocarcinoma  of  the  rectum  proper. 
The  latter  form  is  thirty  times  more  frequent  than  the  former.     Carcin- 


360 


THE    ABDOMEN. 


/ 


oma  of  the  rectum  proper  arises  most  often  in  one  of  two  places:  (a)  In 
the  ampulla,  either  as  a  placque-hke  or  as  an  annular  growth;  (b)  at  the 
junction  of  the  rectum  and  pelvic  colon  (sigmoid).  In  the  second  situa- 
tion the  tumor  most  often  occurs  in  an  annular  form.  The  diagnosis  of 
an  epithehoma  of  the  anus  is  not  difficult.  It  is  found  either  as  (a)  a 
wart-like,  firm  tumor  with  indurated  base,  involving  a  variable  degree 
of  the  circumference  of  the  anal  orifice,  or  as  (b)  sl  crater-hke  ulcer  with 
marked  indurated  edges  and  base.     The  age  of  the  patient  and  the 

characteristic  induration  of 
the  growth  render  a  differ- 
entiation from  ordinary  soft 
venereal  warts  or  hemor- 
rhoids easy.  In  cancer  of 
the  anus  there  is  early  in- 
duration of  the  inguinal 
nodes. 

Carcinoma  of  the  rectum 
proper  is  more  difficult  to 
recognize.  There  are  no 
characteristic  symptoms  for 
this  condition,  but  its  pres- 
ence must  be  thought  of 
when  patients,  above  forty, 
complain  of  diarrhea  ac- 
companied by  the  discharge 
of  pus  and  mucus,  a  sensa- 
tion of  weight,  pain  radiat- 
ing into  the  thighs  and  back, 
and  straining  at  stool. 

In   some   cases,  obstin- 
ate constipation  alternating 
with  attacks  of  diarrhea  and 
the    occasional   passage   of 
blood  will  be  the  only  symptoms.     With  both  of  these  clinical  pictures 
there  is  often  a  gradual  loss  in  weight  and  in  strength. 

If  the  cancer  is  located  high  up  near  the  sigmoid  there  are  indefinite 
symptoms  of  enterostenosis,  cohc-hke  pains,  etc.  (page  309).  In  women 
such  a  tumor  has  been  mistaken  at  times  for  an  ovarian  or  uterine 
tumor,  or  for  a  displaced  uterus.  For  carcinomata  situated  in  the  am- 
pulla digital  examination  will  usually  suffice.  For  those  which  cannot 
be  reached  by  the  finger,  the  use  of  the  proctoscope  cannot  be  too 


Fig.  214. — Carcinomatous  Ulcer  of  Posterior  Wall  of 

Rectum. 

Observe  the  papillomatous  condition   of   the   edges  and  the 

crater-like  excavation  of  the  center  of  the  ulcer. 


RENAL    AND    VESICAL    LESIONS.  36 1 

warmly  recommended.  Bimanual  examination  under  anesthesia  is  also 
of  great  aid  for  these  high-seated  cancers.  The  growth  may  be  felt  as 
a  crater-like  ulcer  with  hard  edges  and  base  situated  only  on  one  side 
of  the  rectal  wall,  or  it  forms  an  annular,  band-like  constriction  which 
causes  the  rectum  to  feel  board-like  and  to  become  firmly  fixed  to  the 
surrounding  structures. 

The  chief  condition  from  which  malignant  stricture  of  the  rectum 
must  be  distinguished  is  syphilis.     This  has  been  considered  on  page  358. 


Renal  and  Vesical  Lesions. 

the  older  and  the  newer  methods  of  diagnosis  of  renal 
and  vesical  lesions. 

The  older  methods  of  diagnosis  may  be  summed  up  as  follows:  (i) 
The  clinical  picture.  (2)  The  examination  of  the  urine.  (3)  The 
objective  examination,  i.  e.,  palpation,  inflation  of  the  colon,  etc. 

The  newer  methods  include:  (i)  Cystoscopy.  (2)  Ureteral  cathe- 
terization. (3)  Chromocystoscopy.  (4)  Cryoscopy  and  (5)  thephlorid- 
zin  test.  (6)  The  use  of  the  x-ray,  with  or  without  the  aid  of  metallic 
sounds.  (7)  Electrical  conductivity  of  the  urine.  (These  newer  methods 
are  discussed  in  the  chapter  upon  Methods  of  Examination, 

The  Older  Methods  of  Diagnosis. 

1.  The  Clinical  Picture. — This  is  of  value  only  when  the  signs  are 
unquestionably  those  of  renal  or  vesical  disease.  Symptoms  which  have 
been  given  in  the  sections  upon  the  diagnosis  of  these  lesions  are  often 
deceptive.  There  may  be  no  pain  in  renal  lesions  or  it  may  be  referred 
to  the  opposite,  or  healthy  kidney.  Frequency  of  urination  may  be 
present  in  both  renal  and  vesical  lesions.  The  pain  in  both  of  these 
conditions  may  be  periodic.  As  Israel  has  shown,  renal  colic  may  be 
present  both  in  pyelitis  and  in  acute  congestion  of  the  kidneys. 

2.  The  Examination  of  the  Urine. — The  reaction  of  the  urine  is 
of  little  value  in  some  cases,  because  a  pyelitis  may  show  an  alkaline  and 
a  cystitis  an  acid  reaction.  In  the  majority  of  cases,  if  blood  is  present 
in  the  urine  and  is  increased  by  movement,  the  case  is  likely  to  be  one  of 
renal  colic,  whereas  a  tumor  causes  spontaneous  hemorrhage.  This 
may  be  reversed  (Casper^).  Again,  a  severe  hemorrhage  may  be  the 
first  symptom  of  a  tuberculosis,  or  a  hematuria  can  occur  without  any 
visible  renal  lesion.     The  diagnosis  of  where  pus  comes  from  as  dcter- 

'  The  author  is  indebted  for  much  valuable  informalion  to  the  excellent  book  of  Casper 
("Handbuch  der  Cystoscopie"). 


362  THE   ABDOMEN. 

mined  by  washing  out  the  bladder  is  also  too  uncertain.  Pus  in  larger 
amounts  usually  means  a  cystitis,  but  one  cannot  draw  conclusions  from 
this,  since  the  same  may  occur  in  a  pyelitis. 

One  cannot  make  a  diagnosis  of  the  location  of  a  lesion,  whether  it 
is  vesical  or  renal,  from  the  presence  of  the  various  forms  of  epithehum 
in  the  urine. 

3.  Objective  Examination. — Palpation  of  a  renal  tumor  is  of 
great  value,  but  unfortunately,  in  many  cases  of  renal  calculus,  neo- 
plasms, or  tuberculosis,  one  cannot  feel  anything,  especially  if  the  patient 
be  very  stout  or  very  thin.  The  larger  of  the  kidneys  may  be  the  hyper- 
trophied  one.  As  was  stated  on  page  305,  an  enlarged  gallbladder  or 
spleen  may  feel  hke  a  kidney.     Inflation  of  the  colon  should  be  tried  in 


Fig.  215. — Apparatus  to  be  Employed  foe  Inflating  the  Colon  for  Diagnostic  Purposes. 
The  rubber  bulb  of  a  PaqueKn  cautery  is  joined  by  means  of  a  glass  tube  to  an  ordinary  rubber  rectal  tube. 

every  case  by  inserting  an  ordinary  rectal  tube  into  the  rectum  (Fig.  215) 
and  forcing  air  through  it  with  the  aid  of  an  ordinary  bicycle  pump  or 
the  bulb  of  a  Paquelin  cautery.  It  may,  however,  be  of  no  value  on 
account  of  the  presence  of  adhesions  or  the  fact  that  the  colon  does  not 
lie  in  front  of  the  kidney  or  it  may  lie  over  the  gallbladder.  The  lower 
part  of  the  ureters  can  often  be  felt  through  the  vagina. 


PYELITIS. 

The  various  causes  of  this  condition  must  be  recalled  in  making  a 
diagnosis.     They  are: 

I.  A  cystitis  followed  by  ascending  infection  of  the  ureter  and  renal 
pelvis.     It  is  most  often  unilateral. 


TUBERCULOSIS    OF   THE    KIDNEY,  363 

2.  As  a  complication  of  renal  calculi  and  of  renal  tuberculosis.  Here 
it  is  also  unilateral  unless  the  respective  condition  is  bilateral. 

3.  By  extension  from  neighboring  foci  of  suppuration.  Here  it  is 
usually  unilateral. 

4.  As  a  primary  condition,  i.  e.,  a  hematogenous  infection. 

As  will  be  seen  by  a  reference  to  these  causes  of  pyelitis,  the  diagnosis 
is  rather  that  of  the  accompanying  condition  than  of  the  pyelitis  itself, 
in  the  majority  of  cases. 

Pyelitis  may  occur  in  an  acute  and  in  a  chronic  form.  Acute  pyelitis 
most  often  follows  ascending  infection  from  the  bladder  or  occurs  as  a 
result  of  hematogenous  infection.  The  diagnosis  may  be  made  from 
the  following : 

1.  Fever.  This  may  be  quite  irregular  and  accompanied  by  recur- 
ring chills,  or  it  may  be  moderate.  Often  the  kidneys  are  not  suspected 
as  the  cause  of  persistent  fever,  especially  in  children. 

2.  Local  signs.  There  are  marked  pain  and  tenderness  over  the 
kidneys  in  many  cases,  but  in  others  there  are  absolutely  no  localizing 
signs  of  inflammation.  Cystoscopic  examination  shows  pus  coming 
from  one  or  both  ureters. 

3.  Urine.  There  is  pus  present  in  large  quantities.  The  reaction 
may  or  may  not  be  acid.  There  is  but  little  albumin  present  unless  a 
nephritis  coexists,  and  there  may  be  many  red  blood-corpuscles.  The 
urine  is  usually  decreased  in  amount  and  there  may  be  reflex  anuria. 

Chronic  pyelitis  is  most  frequently  a  complication  of  renal  calculi, 
tuberculosis,  or  tumors,  or  occurs  as  a  complication  of  a  chronic  cystitis. 
If  the  latter  is  the  cause,  a  diagnosis  of  a  chronic  pyelitis  cannot  be  made 
unless  attacks  of  acute  pyelonephritis  occur  from  time  to  time,  when  its 
presence  may  be  suspected.  In  the  other  affections,  the  diagnosis  is 
made  from  the  cause  of  the  pyelitis. 


TUBERCULOSIS  OF  THE  KIDNEY. 

It  is  at  present  a  well  accepted  fact  that  the  majority  of  cases  are 
due  to  hematogenous  infection,  the  disease  never  being  primary  in  the 
ureter  or  bladder. 

Clinically  there  are  three  modes  of  onset : 

1 .  Those  in  which  the  symptoms  of  cystitis  are  present  which  do  not 
yield  to  the  usual  treatment. 

2.  Those  in  which  the  symptoms  are  those  of  a  chronic  pyehtis,  i.  e., 
pyuria  lasting  for  years  in  some  cases,  before  a  suspicion  of  tuberculosis  is 
aroused. 


564 


THE    ABDOMEN. 


3.  Those  in  which  a  sudden  hematuria  is  the  first  symptom. 

1.  Those  with  symptoms  of  cystitis  constitute  the  majority,  the 
patients  often  being  treated  for  this  for  a  long  time.  The  first  and  earhest 
symptom  noticed  in  this  class  of  cases  is  that  there  is  increased  frequency 
0}  urination,  especially  at  night.  Some  patients  complain  of  being  obliged 
to  urinate  immediately,  or  there  is  vesical  tenesmus  and  burning  at  the 
end  of  urination  and  some  pain. 

2.  In  the  second  mode  of  onset  there  is  a  painless  pyuria  with  little  or 


Fig.  216. — Tuberculosis  of  the  Kidney  in  its  Incipient  Stage. 
I,  Caseous  broken-down  foci  at  apex  of  the  pyramids  in  the  upper  pole  of  the  kidney;   2,  miliary  tubercles 

in  the  cortex. 

no  bladder  irritabihty,  the  urine  is  acid  in  character  and  contains  tubercle 
bacilli. 

3.  In  the  third  class  a  sudden  severe  hematuria  of  brief  duration 
may  be  the  first  symptom  to  direct  attention  to  the  kidneys. 

Symptoms. — In  making  a  diagnosis  one  must  consider  the  following 
symptoms  : 

1.  The  various  modes  of  onset-  as  just  described,  so  that,  in  general, 
pyuria  in  adults  between  twenty  and  forty,  preceded  or  not  by  signs  of 
bladder  irritability,  should  lead  to  further  examination. 

2.  Urinary  Changes. — The  reaction  is  acid,  there  are  but  few  casts, 
there  is  a  trace  of  albumin  in  the  filtered  specimen,  many  pus-cells  and 
tubercle  bacilli.  In  some  cases  the  urine  may  be  quite  clear  at  first. 
Tubercle  bacilh  can  be  best  found  if  several  pints  of  urine  are  used  for 


DIAGNOSIS    OF    RENAL    CALCULI.  365 

sedimentation  and  the  sediment  stained.     If  this  is  unsuccessful  a  guinea- 
pig  should  be  inoculated. 

3.  Pain  and  Renal  Enlargement. — As  a  rule,  there  is  but  little  pain. 
In  some  cases  there  is  a  dull  aching  in  the  lumbar  region  on  one  side,  for 
years.  In  a  few  cases  paroxysmal  attacks  like  renal  colic  occur,  but 
these  are  rare. 

In  the  majority  of  cases  there  is  palpable  enlargement  of  the  affected 
kidney  (nineteen  in  twenty-four  cases  observed  by  Israel),  to  about  twice 
the  normal  size.  Enormous  enlargement  is  infrequent.  The  kidney, 
if  palpable,  is  tender,  and  in  thin  women  one  may  also  feel  the  greatly 
thickened  ureter  as  a  hard,  tender  cord. 

4.  General  Symptoms. — The  entire  body  should  be  searched  for 
primary  foci.  Every  patient  will  show  a  gradual  loss  in  weight  and 
strength  and  increasing  anemia;  this  is  most  marked  if  both  organs  are 
involved.  There  may  be  either  fever  of  an  intermittent  type  or  a  differ- 
ence of  one  to  three  degrees  between  the  morning  and  evening  tempera- 
ture (hectic  type) . 

The  injection  of  tuberculin  is  justifiable,  and  is  indicated  if  tubercle 
bacilli  cannot  be  found. 

5.  Cystoscopic  Examination  and  Ureteral  Catheterization. — The  im- 
provements in  this  direction  have  greatly  aided  in  making  an  early 
diagnosis  of  this  affection  possible  and  their  use  should  never  be 
neglected. 

Through  the  cystoscope  one  can  see  ulcerations  in  the  bladder  around 
the  ureteral  orifices  (Kummell).  The  edges  of  these  are  everted,  and 
there  is  an  irregular,  dentated,  funnel-like  ulcer  present  (golf-hole  orifice). 

When  there  are  ho  such  vesical  changes,  only  catheterization  of  the 
ureters  will  show  the  kidney  affected,  and  this  can  now  be  done  on  the 
suspected  side  only. 


DIAGNOSIS  OF  RENAL  CALCULI. 
In  some  cases  renal  calcuH,  like  gallstones,  may  be  present  without 
causing  any  symptoms.     There  are,  in  general,  two  classes  of  cases: 

1.  Those  in  which  symptoms  directly  referable  to  the  kidney  appear, 
as  renal  colic,  hematuria,  or  anuria.  "^ 

2.  Those  in   which   there  are  no  active  sym])toms,   the  so-called 
quiescent  cases. 

I.  Those  in  which  active  renal  s}'mptoms  appear. 
In  the  majority  of  these  patients  it  is  the  occurrence  of  one  or  more 
attacks  of  renal  colic  which  attracts  the  attention  of  the  physician.     The 


366 


THE    ABDOMEN. 


first  point  to  determine  in  these  cases  is  whether  the  attack  had  all  of  the 
characteristics  of  a  typical  renal  colic.  The  second  fact  is  to  ascertain 
by  a  process  of  exclusion,  whether  the  attack  of  pain,  etc.,  might  not  be 
due  to  other  renal  or  ureteral  conditions  which  produce  colic. 

Renal  colic  has  been  discussed  on  page  270  as  an  acute  abdominal 
condition.  The  principal  affections  from  which  such  an  attack  must  be 
differentiated  have  also  been  referred  to  These  were  appendicitis, 
intestinal  obstruction,   and    gallstones.     We  must    now  consider    the 

second  question  in  the  diagnosis  of 
active  cases,  i.  e.,  those  producing 
attacks  of  renal  cohc. 

This  problem  is  to  exclude  all 
other  renal  conditions  which  might 
cause  colic.  There  are  three  classes 
of  cases  which  might  cause  renal 
colic.  These  are :  (a)  Those  which 
produce  obstruction  of  the  ureter. 
These  are  floating  kidney  (kink- 
ing of  ureter) ,  pyonephrosis  (plug- 
ging of  ureter  by  pus),  neoplasms 
(plugging  by  blood  or  tumor 
masses),  tuberculosis  (plugging  by 
blood  or  caseous  particles).  (&) 
Those  which  produce  cohc  with- 
out obstruction.  These  are  acute 
congestion,  such  as  occurs  in  tu- 
berculosis, acute  exacerbations  of 
chronic  nephritis,  pyehtis,  hyper- 
acidity of  the  urine,  and  nephralgia. 
(c)  Colics  due  to  diseases  of  the 
ureter,  such  as  ureteritis,  strictures,  or  pressure  of  tumors  from  without. 
The  majority  of  attacks  of  renal  colic  are  due  to  calculi,  yet  it  is  well 
to  bear  all  of  these  other  causes  in  mind  in  making  a  diagnosis.  The 
accompanying  symptoms  of  all  of  the  affections  mentioned  will  usually 
enable  one  by  exclusion  to  state  that  the  attack  was  one  of  renal  colic  due 
to  calculi. 

In  addition  to  these  renal  colics,  the  diagnosis  can  be  made  in  these 
active  cases  from  the  same  symptoms  and  objective  findings  as  in  the 
quiescent  cases. 

2.  Diagnosis  in  the  quiescent  stage,  i.  e.,  when  no  coHcs  are  present. 
These  cases  occur  clinically  in  two  forms. 


Fig.  217. — artciiiL-N  u¥  Calculous  Pyelonephri- 
tis. 
The  specimen  shows  many  calculi  in  situ  both 
in  the  cortex  and  pelvis  of  kidney.  Note  the  exten- 
sive destruction  of  the  cortex  through  the  suppur- 
ative condition  following  the  presence  of  calculi. 


DIAGNOSIS    OF   RENAL    CALCULI, 


567 


(a)  Those  in  which  the  symptoms  are  referred  to  other  organs  until 
a  cohc  or  hematuria  occurs,  e.  g.,  cases  treated  as  floating  kidney, 
cystitis,  gallstones,  chronic  rheumatism,  lumbago,  intercostal  neuralgia, 
dyspepsia,  and  uterine  or  adnexal  disease. 

(b)  Those  in  which  there  are  distinct  symptoms  referable  to  the 
kidneys. 

The  symptoms  of  both  forms  may  be  one  or  more  of  the  following : 

Pain. — This  is  either  of  a  continuous  or  of  an  intermittent,  dull,  aching 
character,  referred  to  the  lumbar  region,  or  there  is  a  sensation  of  weight 
or  pressure.  The  pain 
is  very  commonly  spon- 
taneous, but  is  often  in- 
creased by  exertion,  or 
the  pains  may  occur  at  a 
certain  hour. 

Results  of  Palpation. 
■ — Unless  infection  has 
occurred  in  a  calculous 
kidney,  or  calculi  are 
combined  with  a  neo- 
plasm or  tuberculosis,  no 
palpable  enlargement  of 
the  kidney  is  found.  Ac- 
cording to  Israel,  such 
enlargement  was  found  in 
twenty-two  out  of  thirty 
cases,  due  either  to  sep- 
tic infection  or  the  result 
of  hpomatous  changes. 

Tenderness  of  the  af- 
fected kidney  will  often 

be  complained  of  on  bimanual  palpation.  This  is  most  marked  at  the 
end  of  a  long  expiration.  The  pain  is  felt  either  along  the  ureter  or  in 
the  bladder  or  penis,  occasionally  in  the  opposite  kidney.  The  ureter  is 
often  tender,  especially  where  it  crosses  the  pelvic  brim. 

A  shaking  of  the  lumbar  region  or  suddenly  extending  the  thigh 
after  it  has  been  flexed  on  the  body  will  in  some  cases  cause  a  sharp  pain 
in  the  affected  kidney. 

The  tension  and  resistance  of  the  muscles  on  the  affected  side  is  often 
much  more  marked  than  on  the  opposite  one. 

Urinary  Changes. — Careful  search  of  the  urine  will  at  some  time  show 


41 


W 


^  • 


4^ 


Fig.  218. — Renal  Calculi  after  Removal  from  the  Kidney. 
These  are  the  same  as  shown  in  Figs.  217  and  219.  Note  the 
variation  in  size  and  shape.  The  round  ones,  like  gallstones  of 
small  sizes,  can  be  passed  spontaneously,  but  the  irregular  ones 
usually  are  lodged  in  one  of  the  calices  of  the  pelvis. 


368  THE    ABDOMEN. 

the  presence  of  red  corpuscles.  These  are  generally  of  the  shadow 
variety,  i.  e.,  the  hemoglobin  has  been  washed  out.  There  is  also  a 
trace  of  albumin  in  uncomplicated  cases. 

The  finding  of  this  combination  of  washed-out  red  corpuscles  and  a 
trace  of  albumin  is  the  most  characteristic  urinary  finding,  according  to 
Israel,  in  aseptic  cases. 

If  infection  of  either  the  pelvis  or  the  kidney  has  occurred,  pus  is 


Fig.  219. — Skiagraph  of  Rkxai.  Calculi  taken  \mih   ihl  Aiu  ui-  a  i  .jc using  Tube. 
The  shadows  of  the  calculi  have  been  outlined  in  white.     XI,  Eleventh  rib;    XII,  twelfth  rib. 

found  in  varying  quantities.  The  presence  of  crystals  of  uric  acid,  etc., 
is  of  no  value. 

Hematuria,  instead  of  being  microscopic  only,  may  be  very  profuse 
and  be  the  first  sign  of  calculus.  In  such  cases  a  differentiation  from 
tuberculosis,  neoplasm,  and  unilateral  or  bilateral  chronic  hemorrhagic 
nephritis  may  be  very  difficult. 

In  calculus  the  hematuria  is,  in  general,  more  dependent  on  exertion, 
while  in  tuberculosis  and  neoplasms  this  is  not  the  case.  Unless  infection 
has  occurred,  the  urine   in   tuberculosis  is  likely  to  contain  both  red 


DIAGNOSIS    OF   RENAL    CALCULI. 


569 


corpuscles  and  pus,  and  in  the  latter  there  are  tubercle  bacilli.  In 
nephritis  there  would  be  casts  and  a  larger  percentage  of  albumin.  It  is 
well  to  remember  that  both  tuberculosis  and  tumor  may  be  associated 
with  calculi. 

The   characteristics   of   the   urine   in    intermittent   hydronephrosis 
have  been  referred  to  (page 

3^3)- 

It  is  always  best  to  col- 
lect the  urine  for  twenty- 
four  hours  in  every  case  of 
suspected  renal  calcuh  and 
examine  a  centrifugated 
specimen.  One  must  also 
remember  that  the  passage  of 
uric  acid  or  oxalate  of  lime 
crystals  may  cause  red  blood- 
corpuscles  to  be  present  in 
the  urine. 

Disturbances  in  Micturi- 
tion.— These  may  be  so 
marked  both  as  to  frequency 
and  urgency,  that  the  case  is 
suspected  to  be  one  of  cys- 
titis. In  some  cases  there  is 
pain  on  urination  referred  to 
the  side  of  the  bladder  cor- 
responding to  the  location  of 
the  calculus  in  the  kidney. 

Radiographic  Examina- 
tion.— There  can  no  longer 
be  any  doubt  that  every  case 
of  suspected  renal  or  ureteral 
calculi  should  be  subjected  to 
this  method  of  diagnosis.  In- 
structions as  to  the  preparation  of  the  patient  will  be  found  in  the  special 
books  on  this  subject. 

Calcuh  differ  in  the  intensity  of  the  shadows  which  they  cause. 

Oxalate  calculi  give  the  sharpest,  the  urates  come  next,  while  phosphatic 

stones  give  the  least  shadow,  and  pure  uric  acid  scarcely  ever  gives  a 

shadow. 

A  kidney  may  contain  numerous  calculi  and  yet  onlv  one  or  two  will 
24 


Fig.  220. — X-RAY  OF  a  Kidney  Removed  on  Account  of 
Extensive  Destruction,  due  to  Calculous  Pye- 
lonephritis. 

The  illustration  was  made  by  taking  the  kidney  after 
it  was  extirpated  and  laying  it  upon  an  a-ray  plate,  and  then 
exposing  it  to  the  tube,  i ,  Renal  calculus  which  casts  an 
intense  shadow;  2,  small  calculus  which  tlirows  very  slight 
shadow.  This  is  the  same  kidney  as  is  shown  in  the  x-ray. 
Fig.  219,  and  illustrates  that  many  renal  calculi  do  not  cast  a 
sufEciently  deep  shadow  to  be  detected  in  a  skiagraph  dur- 
ing life.  The  :x--ray  shown  in  Fig.  219  reveals  only  three 
shadows,  whereas  the  kidney  skiagraph  taken  after  extirpa- 
tion shows  many  more  calculi. 


370 


THE    ABDOMEN. 


give  a  shadow  (Fig.  219).  Again,  we  must  not  overlook  the  possi- 
bihty  of  calcified  mesenteric  glands  or  calcareous  deposits  simulating 
the  calculous  shadows.  In  the  case  of  ureteral  stones,  where  the 
error  is  most  Hkely  to  occur,  this  can  be  ehminated  by  taking  a  picture 
before  and  after  passing  a  metal  ureteral  bougie. 

At  present  our  standpoint  is  that  with  proper  apparatus,  experience, 

and  not  too  fat  a  subject,  it  is 
possible  to  detect  both  renal 
and  ureteral  calculi  by  this 
method  in  the  majority  of 
cases.  A  negative  result  after 
repeated  exposures  excludes 
the  presence  of  calculi. 

Examination  of  the  Bladder 
and  Ureters. — In  some  cases 
confirmatory  evidence  of  which 
kidney  the  hematuria  comes 
from  may  be  obtained  by  the 
use  of  a  cystoscope  or  the  use 
of  the  Harris  segregator  or 
Luys  apparatus.  Of  these, 
the  cystoscope  is  the  most 
accurate,  but  requires  the 
greatest  experience  and  dex- 
terity. 

If  the  hematuria  is  quite 
marked  ureteral  catheteriza- 
tion may  be  advisable  (see 
page  732). 

Anuria. — In  some  cases  a 
sudden  cessation  of  the  secre- 
tion of  urine  may  be  the  first 
sign  of  a  calculus.  Although 
such  a  calculus  impacted  in  the  beginning  of  the  ureter  may  be  the  most 
frequent  cause  of  anuria,  there  are  other  causes  which  must  be  excluded, 
such  as  bilateral  acute  or  chronic  nephritis,  obstruction  of  both  ureters 
by  tumors  (uterine  carcinoma),  operations  on  one  kidney  and  reflex 
anuria  of  the  opposite  one,  or  anuria  due  to  kinking  of  the  ureter. 

The  history  and  accompanying  symptoms  will  usually  enable  one  to 
make  a  diagnosis  of  the  cause  of  the  anuria. 


Fig.  221. — Specimen  of  Double  Ureter  Formation. 
RK,  Right  kidney;  LK,  left  kidney,     i,  Right  ureter; 
'2  and  3,  represent  the  separate  ureters  present  upon  the 
left  side;  4,  rudimentary  uterus;  s,  bladder. 


THE    BLADDER — CONGENITAL    MALFORMATIONS. 


371 


The  Bladder, 
congenital  malformations. 
Ectopia  Vesicae  or  Exstrophy  of  the  Bladder. — The  most  frequent 
form  is  the  one  in  which  the  entire  anterior  wall  of  the  bladder  and  the 
abdominal  wall  over  it  is  not  present. 

The  posterior  wall  of  the  bladder  presents  itself  as  a  red,  easily  bleed- 
ing mass  which  projects  beyond  the  level  of  the  surrounding  skin  (Fig. 
222).     Associated  with  it  are  usually  found  a  non-union  of  the  pubic 


Fig.  222. — View  of  Ectopia  Vesica  in  Same  Patient  shown  in  Fig.  223. 
U.,   Congenital  hernia;     F,  prolapsed  posterior  wall  of  bladder;  £,  epispadias. 


bones,  a  lack  of  development  and  deformity  (epispadias)  of  the  penis, 
and  a  congenital  hernia  (Fig.  223). 

The  condition  can  be  readily  recognized  by  the  red  protrusion  above 
the  pubis,  from  which  urine  constantly  escapes,  causing  irritation  of  the 
surrounding  skin. 

To  prove  the  nature  of  the  protrusion  one  can  lift  it  up  a  little  and 
watch  the  jet  of  urine  escape  from  the  ureteral  papillae  and  pass  line 
catheters  or  probes  into  these  (Fig.  223). 

The  deformity  is  more  often  present  in  females  than  in  males. 


372 


THE    ABDOilEX. 


WOUNDS  OF  THE  BLADDER. 

The  diagnosis  of  these  has  been  described  in  connection  with  injuries 
of  the  abdominal  viscera  in  general  (page  243). 

INFLAMMATION  OF  THE  BLADDER. 

Cystitis. — Chnically,  the  division  of  cystitis  into  the  acute  and  chronic 
forms  is  the  most  convenient. 

Acute  Cystitis. — Tlie  most  important  s}Tnptoms  from  which  a 
diagnosis  is  made  are : 

I.  Painful  and  Increased  Frequency  of   Urination. — The  urine  is 


r 


H 


Fig.  223. — EcTOPLA.  Vesica  Accoirp-AJs-izD  by  Epispadias  and  Congexital  Right-sided  Hernia. 
E,  Epispadias.      Posterior  wall  of  the  bladder  is  seen  prolapsed  through  the  hiatus  in  abdominal  wall. 
H,  Congenital  right-sided  inguinal  hernia.     Two  catheters  are  shown  passing  into  tlie  left  and  right  ureters 
respectively.     The  orifices  of  the  ureters  are  situated  close  to  the  junction  of  the  lower  border  of  the  prolapsed 
bladder  with  the  abdominal  wall. 


voided  at  shorter  intervals  than  normal.  The  patient  has  the  feeling 
of  being  obHged  to  pass  the  urine  immediately  after  the  desire  is  felt 
(urgency  of  micturition;.  The  pain  increases  with  each  urination,  and 
the  act  itself  is  followed  by  marked  vesical  tenesmus,  so  that  the  patient 
in  severe  cases  has  an  almost  constant  desire  to  urinate.  Complete 
retention  may  occur,  only  the  overflow  being  involuntarily  voided. 


INFLAMMATION    OF   THE    BLADDER.  373 

2.  Sensation  of  Weight  and  Tenderness. — This  is  often  quite  marked 
in  the  hypogastric  region  and  perineum. 

3.  The  Urine. — In  the  majority  of  cases  the  freshly  voided  urine  is 
acid,  but  soon  becomes  neutral  or  alkaline.  The  urine  is  turbid  owing 
to  the  presence  of  large  amounts  of  pus-corpuscles.  The  more  alkahne 
the  reaction,  the  more  marked  is  the  ammoniacal  odor  and  the  larger  the 
number  of  triple  phosphates  and  mucus  present. 

4.  General  Symptoms. — There  is  usually  a  moderate  rise  of  tempera- 
ture with  anorexia  and  sleeplessness.  In  some  cases  the  disease  is 
ushered  in  by  a  chill  followed  by  a  rise  of  temperature  of  var}'ing  in- 
tensity and  with  irregular  exacerbations. 

In  diphtheritic  cystitis  all  of  the  above  symptoms  are  more  marked, 
especially  the  pain  and  ammoniacal  urine.  The  fever  runs  a  course 
Hke  a  typhoid  and  there  are  signs  of  severe  sepsis,  such  as  delirium, 
sweats,  and  rapid  pulse. 

Chronic  Cystitis. — This  arises  either  from  the  acute  variety  or  begins 
as  a  subacute  process  which  becomes  a  chronic  one. 

The  symptoms  mentioned  above  are  all  less  marked.  Pain  is  but 
slight  and  often  consists  only  of  a  mild  burning  sensation  on  urinating. 
The  increased  frequency  and  urgency  of  micturition  are  quite  marked, 
especially  after  exposure  to  cold  or  errors  in  diet. 

After  the  urine  has  been  passed  there  is  always  some  residual  urine, 
since  the  disease  is  most  common  where  some  obstruction  exists,  such  as 
prostatic  hypertrophy  or  stricture  of  the  urethra  or  prolapse  in  women. 
In  those  cases  which  follow  an  acute  cystitis,  this  residual  urine  symptom  is 
seldom  present.  The  frequent  desire  to  urinate  is  especially  marked 
at  night. 

The  urine  is  often  alkaline  in  reaction,  containing  much  pus,  epithe- 
lial cells,  and  triple  phosphates. 

The  complications  of  acute  cystitis  are  a  gangrene  of  the  bladder 
wall,  causing  pyemia  and  death,  or  the  ulceration  which  may  rarely  go  on 
to  perforation  or  peritonitis,  or  an  acute  pyelonephritis  (page  251). 

The  complications  of  chronic  cystitis  are: 

{a)  A  pyelitis  or  pyelonephritis. 

(&)  The  formation  of  abscesses  in  the  bladder  wall  or  of  a  peri^'csical 
phlegmon  in  front  of  or  behind  the  organ. 

(c)  The  perforation  of  the  diverticula  which  often  form  in  these 
cases,  causing  peritonitis  or  prevesical  abscess  (page  232). 

(d)  A  chronic  condition  of  septic  intoxication  called  urosepsis,  from 
the  absorption  of  toxic  products  from  the  decomposing  urine.  The 
signs    of    this    are    frequently    recurring    chills    followed    by    profuse 


374  THE    ABDOMEN. 

sweats  and  rise  of  temperature,  vomiting,  delirium,  and  a  gradual 
loss  in  weight. 

Differential  Diagnosis  of  Cystitis. — Renal  Suppuration. — Al- 
though there  are  bladder  symptoms,  these  appear  and  disappear 
without  any  special  cause,  while  the  quantity  of  pus  remains  constant 
and  is  greater  than  in  a  cystitis. 

Posterior  Urethritis  or  Prostatitis. — In  both  of  these  conditions,  as  in 
acute  cystitis,  there  is  increased  frequency  of  and  painful  micturition. 
The  other  differential  diagnostic  points  are  given  on  page  381. 


TUBERCULOSIS  OF  THE  BLADDER. 

This  condition  is  secondary  to  the  same  affection  in  the  kidneys  in  both 
sexes,  or  in  the  male  may,  in  addition,  be  secondary  to  a  primary 
focus  in  the  testis  with  resultant  ascending  infection.  A  priman."  tuber- 
culosis is  very  rare. 

In  the  majority  of  cases  the  disease  apparently  occurs  spontaneously. 
A  hematuria  may  often  be  the  first  sjmiptom,  followed  by  painful  and 
increased  frequency  of  micturition.  The  blood  is  passed  in  large  clots 
and  is  not  intimately  mixed  with  the  urine,  as  it  would  be  in  a  renal 
hematuria.  In  other  cases  the  vesical  tuberculosis  develops  in  a  latent 
manner  as  a  complication  of  a  gonorrheal  cystitis.  The  urine  in  the 
early  stages  is  acid  and  there  is  but  little  pus;  later  it  is  alkaline  and 
there  is  considerable  pus  and  mucus.  Tubercle  bacilli  may  be  found  in 
centrifugated  specimens  if  a  large  quantity  of  urine  is  used,  or  some  of 
the  pus  can  be  injected  into  a  guinea-pig. 

The  diagnosis  is  easy  if  the  above  symptoms  are  found  in  a  person 
who  has  a  primary  focus  of  tuberculosis  elsewhere  which  can  be  readily 
detected. 

Every  pyuria  or  hematuria  occurring  in  young  persons  without  any 
apparent  cause  should  lead  to  the  suspicion  of  a  vesical  or  renal  tubercu- 
losis. Hematuria  due  to  cancer  occurs  at  an  older  period,  while  that 
due  to  calculi  usually  ceases  when  the  patient  is  kept  quiet,  while  rest 
has  no  influence  on  the  hematuria  of  tuberculosis. 

By  the  aid  of  the  cystoscope  one  can  detect  ulcerations  at  the  orifices 
of  the  ureters  and  the  neck  of  the  bladder.  The  presence  of  renal 
symptoms  and  the  escape  of  pus  from  the  corresponding  ureter  help  to 
confirm  the  diagnosis.  The  crucial  test,  however,  is  the  discover}-  of 
tubercle  bacilh  either  by  staining  or  the  guinea-pig  inoculation  test. 


VESICAL   CALCULI.  375 

VESICAL  CALCULI. 

The  characteristic  symptoms  of  stone  in  the  bladder  are  pain,  hemor- 
rhage, and  disturbances  of  micturition.  These  are  very  frequently 
combined  with  the  symptoms  of  chronic  cystitis,  or  of  hypertrophy  of  the 
prostate,  so  that  the  cHnical  picture  becomes  a  complex  one. 

(a)  The  pain  is  felt  in  the  end  of  the  penis,  especially  toward  the 
end  of  urination,  or  the  pain  may  be  felt  at  the  neck  of  the  bladder,  es- 
pecially upon  exertion  or  sudden  jarring  of  the  body.  The  pains  may 
radiate  to  the  rectum,  testis,  or  thigh. 

If  the  calculus  is  pointed  and  becomes  fixed  in  the  meatus  internus, 
the  pain  is  often  excruciating,  and  is  increased  by  each  vesical  contraction. 

(b)  Micturition  is  seldom  normal.  There  is  usually  increased  fre- 
quency. If  the  stone  is  small  the  stream  is  often  suddenly  interrupted. 
In  some  cases  there  is  enuresis,  in  others  retention  of  urine,  especially  if 
the  calculus  becomes  wedged  in  the  internal  meatus.  Obstinate  enuresis 
and  dysuria  are  often  the  first  signs  in  children. 

(c)  Condition  of  urine.  This  contains  pus  and  mucus,  varying  ac- 
cording to  the  degree  of  cystitis.  Blood  in  small  quantities  is  often 
mixed  with  the  urine,  especially  after  any  exertion.  One  specimen  may 
contain  blood  and  the  next  be  perfectly  clear.  In  general,  the  hematuria 
is  never  as  marked  nor  as  continuous  as  in  neoplasms  or  tuberculosis, 
unless  the  latter  coexist. 

In  children,  prolapse  of  the  rectum  and  straining  at  stool  or  in  urina- 
tion, or  the  presence  of  hernise,  should  lead  to  the  suspicion  of  calcuh. 
The  history  of  a  previous  renal  colic  may  be  of  great  value.  The  diag- 
nosis of  vesical  calculus  can  be  confirmed  by  one  or  more  of  the  three 
following  methods  of  examination : 

(i)  The  use  of  a  specially  constructed  sound  called  the  "Thompson 
stone  searcher"  or  the  ordinary  metal  urethral  sounds  of  varying  sizes. 

The  bladder  should  contain  two  ounces  of  fluid  in  children  and  four 
ounces  in  adults,  the  organ  having  been  previously  irrigated  with  boric 
acid  solution  through  a  soft-rubber  catheter.  Some  2  per  cent,  eucain 
solution  is  injected  into  the  deep  urethra.  If  the  bladder  is  very  sensi- 
tive a  general  anesthetic  should  be  given.  If  the  urine  is  ammoniacal, 
the  examination  should  be  preceded  for  a  few  days  to  a  week,  if  possible, 
by  daily  irrigations  and  the  internal  use  of  urinary  antiseptics.  The 
bladder  should  be  systematically  explored.  The  horizontal  position 
with  elevation  of  the  pelvis  is  best  suited  for  these  cases. 

If  the  prostate  is  enlarged,  a  sound  with  a  much  larger  curve  is  neces- 
sary.    When  the  sound  strikes  a  stone,  there  is  a  sharp  metallic  click. 


376  THE   ABDOMEN. 

A  stone  which  is  hidden  in  a  diverticulum  or  deeply  in  the  retroprostatic 
pouch  is  often  found  with  great  difhculty.  The  former  may  be  suspected 
if  the  sound  only  strikes  it  in  one  position  and  cannot  be  made  to  pass 
around  the  calculus. 

(2)  Cystoscopic  examination.  This  is  an  almost  infallible  method, 
and  is  especially  valuable  in  the  case  of  calculi  which  lie  in  diverticula, 
or  for  foreign  bodies  in  the  bladder.  Its  use  may  be  very  difficult  if 
there  is  much  cystitis  or  marked  prostatic  h5qDertrophy. 

(3)  Skiagraphic  examination.  This  method  has  been  used  consider- 
ably since  the  introduction  of  the  x-ray.  As  in  the  cases  of  renal  calculi, 
phosphatic,  oxalate,  and  cystin  give  deep,  while  urate  and  uric  acid 
calculi  only  cause  light  shadows.  The  method  is  only  of  value  if  the 
result  is  a  positive  one.  No  reliance  can  be  placed  upon  a  negative 
picture. 


TUMORS  OF  THE  BLADDER. 

These  are  divided  chnically  into  the  benign  and  malignant.  The 
majority  of  the  former  are  papillomata  made  up  of  long  pedicles 
or  sessile,  warty  tumors  with  a  broad  base.  They  may  be  single 
or  multiple  and  are  most  often  situated  near  the  trigone,  and  not  in- 
frequently become  malignant  in  character.  Of  the  malignant,  the 
majority  are  primary  either  in  the  prostate  or  in  one  of  the  neighbor- 
ing structures  (rectum,  uterus,  etc.).  The  diagnosis  of  a  vesical  neo- 
plasm may  be  made  from  the  presence  of  (a)  sudden  hematuria  which  is 
not  renal  in  origin,  accompanied  by  pain  and  disturbances  of  micturition, 
and  (b)  the  results  of  the  examination  of  the  urine,  and  of  cystoscopic  and 
rectal  examination. 

(a)  The  hematuria  may  be  the  first  symptom,  as  it  is  of  other  renal 
and  vesical  conditions  (calculi  and  tuberculosis).  In  tumors  it  is  the 
first  sign  of  the  condition  in  the  majority  of  cases.  If  the  blood  comes 
from  the  kidney  it  is  intimately  mixed  with  the  urine,  has  been  accom- 
panied by  colic,  and  there  are  often  worm-like  coagula.  In  hemorrhage 
from  the  urethra  the  liquid  or  clotted  blood  precedes  the  voiding  of  urine. 
In  bladder  hemorrhages  the  first  urine  contains  but  little  blood,  but  the 
amount  is  gradually  increased  until  pure  blood  is  evacuated. 

The  hematuria  from  benign  tumors  is  often  intermittent,  occurring 
without  any  cause,  is  not  increased  by  exertion,  and  is  bright  red.  In 
malignant  growths  the  hemorrhage  is  more  persistent,  smaller  in  amount, 
and  more  brownish  in  color. 

Frequency  and  urgency  of  micturition  are  generally  absent  in  smaller 


ENLARGEMENT    OF   THE    PROSTATE.  377 

benign  and  malignant  growths.  In  larger  ones  there  is  often  great 
difficulty  in  micturition  and  even  retention  of  urine. 

Pain  is  generally  absent  in  papillomata  and  is  not  marked  in  the 
carcinomata  until  the  infiltration  is  extensive  or  the  bladder  becomes 
infected.     It  is  then  not  only  present  during,  but  also  between,  urination. 

The  discovery  of  some  of  the  villi  of  a  papilloma  is  one  of  the  most 
positive  signs,  but  this  is  not  often  found.  In  the  malignant  tumors 
which  are  primary  in  the  prostate,  rectal  examination  will  show  a  much 
harder,  stone-like  enlargement  of  the  gland  than  is  the  case  in  ordinary 
hypertrophy.  In  a  recent  case  the  writer  was  led  to  suspect  a  malignant 
prostate  from  the  palpation  of  very  firm  lymph-nodes  in  both  inguinal 
regions  of  a  cachectic  man  who  had  bladder  symptoms.  Rectal  exami- 
nation revealed,  in  addition  to  the  hard  prostate,  a  stricture  due  to  the 
extension  of  the  growth  around  the  rectum. 

In  a  recent  article  on  cancer  of  the  prostate,  Young  ^  calls  attention 
to  this  stony  induration,  as  well  as  to  a  similar  condition  of  the  seminal 
vesicles. 

Cystoscopic  examination  is  of  great  value.  It  is  very  difficult  to 
examine  the  bladder  in  cases  of  villous  tumor,  owing  to  the  hemorrhage, 
but  if  this  latter  is  not  too  great,  the  view  obtained  confirms  the  diagnosis. 

In  malignant  tumors  without  marked  projection  above  the  level 
of  the  bladder  wall,  the  diagnosis  with  the  cystoscope  is  very  difficult, 
but  even  in  these  cases  it  is  often  confirmatory,  especially  in  disease  of  the 
prostate  which  has  invaded  the  trigone. 

Wherever  there  is  any  doubt  as  to  the  nature  of  the  tumor  an  explora- 
tory suprapubic  cystostomy  is  advisable  in  order  that  an  early  diagnosis 
be  made. 


Affections  of  the  Prostate, 
enlargement  of  the  prostate. 

Increased  frequency  of  urination,  often  first  noticed  at  night,  in  a 
man  above  forty,  directs  attention  to  the  bladder  and  prostate.  There 
is  not  only  a  desire  to  urinate  more  frecjuently,  but  a  feeling  that  it  must 
be  passed  immediately.  The  act  requires  longer  than  usual,  and  the 
stream  lacks  the  force  of  a  normal  individual. 

Retention  of  urine  may  begin  gradually,  the  patient  being  able  to 
pass  less  and  less.  It  often  begins  suddenly  after  exposure  to  cold, 
debauches,  or  voluntary  retention  of  the  urine  for  a  long  period. 

Pain  is  not  a  symptom  of  this  condition  until  a  cystitis  has  begun. 

'  "Johns  Hopkins  Hospital  Bulletin,"   October,  1905. 


378  THE   ABDOMEN. 

Hematuria  may  at  times  be  very  profuse  from  the  varicose  prostatic 
veins  around  the  neck  of  the  bladder.  With  the  above  history  one  can 
usually  confirm  the  diagnosis  by  a  systematic  objective  examination. 

This  should  include: 

1.  Palpation  of  the  prostate  through  the  rectum  to  determine  the 
extent  of  the  enlargement  in  this  direction,  whether  one  or  both  of  the 
lateral  lobes  are  involved,  and  the  consistency  and  nature  of  the  enlarge- 
ment. A  fibrous  prostate  is  but  little  enlarged  and  is  very  firm  and 
fiixed.     An  adenomatous  prostate  is  larger,  softer,  and  more  movable. 

2.  Combined  examination  by  the  use  of  a  metal  catheter  inserted 
into  the  bladder,  while  the  index-iinger  is  introduced  into  the  rec- 
tum. In  passing  the  catheter  the  following  points,  according  to  Deaver, 
favor  the  diagnosis  of  enlarged  prostate,  (a)  Undue  depression  of 
the  shaft  is  necessary  before  the  catheter  enters  the  bladder,  (b)  The 
length  of  the  urethra,  i.  e.,  before  urine  comes,  is  more  than  eight  inches. 
(c)  The  catheter  is  deviated  to  one  or  the  other  side  by  the  unequal 
lateral  lobes,  (d)  If  an  obstruction  is  encountered  at  a  distance  of  more 
than  seven  inches  from  the  external  meatus,  showing  that  the  obstruction 
is  not  due  to  strictures  which  never  occur  in  the  prostatic  urethra. 

3.  Determination  of  the  amount  of  residual  urine  by  allowing  the 
patient  to  evacuate  the  bladder  and  then  inserting  either  a  metal  or  a 
special  prostatic  catheter,  known  as  the  Mercier,  with  a  short  beak,  and 
allowing  the  residual  urine  to  escape. 

4.  A  thorough  examination  of  both  the  quantity  of  urine  passed  in 
twenty-four  hours  and  its  constituency. 

5.  By  rotating  the  metal  catheter  around  in  the  bladder  gently,  one 
can  gain  an  idea  of  whether  it  is  dilated  or  contracted,  and  also  whether 
any  calculi  exist.  A  contracted  bladder  accompanies  a  fibrous,  a  dilated 
an  adenomatous  prostate. 

6.  The  cystoscope  is  of  great  confirmatory  value  if  it  can  be  used, 
although  this  may  be  very  difiicult. 

Differential  Diagnosis, — Cancer  of  the  Prostate. — The  induration 
of  the  enlargement  as  palpated  per  rectum  is  more  stony  and  involves 
the  seminal  vesicles  at  an  early  period  in  a  similar  induration. 

There  is  often  early,  sharp,  shooting  pain  along  the  inner  side  of  the 
thighs  or  along  the  sciatic  nerves.  It  also  causes  early  cachexia,  and 
cystoscopic  examinations  fail  to  detect  much  enlargement  toward  the 
bladder  unless  a  previous  benign  enlargement  has  existed.  The  inguinal 
glands  are  also  of  stony  hardness  and  enlarged.  Sarcomata  are  very 
rare  and  grow  very  rapidly. 

Polyps  0}  the  Bladder  {Fibrous). — These  are  quite  rare  and  cause 


URETHRA   AND    PENIS — CONGENITAL    MALFORMATIONS.  379 

obstruction  symptoms  like  an  enlarged  middle  lobe.  Rectal  palpa- 
tion usually  shows  an  absence  of  enlargement  of  the  prostate.  The 
frequency  of  hematuria  and  a  cystoscopic  examination  will  aid  in  dis- 
tinguishing it. 

Tuberculosis  of  the  Prostate. — This  may  cause  enlargement  of,  and 
the  formation  of  nodules  in,  the  prostate.  The  disease  is  rarely  primary. 
The  diagnosis  may  usually  be  made  from  the  presence  of  the  same  dis- 
ease in  the  epididymis  and  the  fact  that  it  generally  occurs  at  an  earher 
age  than  prostatic  hypertrophy. 

The  diagnosis  of  carcinoma  of  the  prostate  has  been  considered  on 
page  378,  while  that  of  tuberculosis  of  the  prostate  will  be  referred  to  in 
connection  with  the  sahie  disease  in  the  male  productive  organs  (page 
379).  Inflammations  of  the  prostate  are  discussed  in  connection  with 
their  most  frequent  etiologic  factor,  viz.,  gonorrhea  (page  381). 


Injuries  and  Diseases  of  the  Urethra  and  Penis, 
congenital  malformations. 

Epispadias  and  Hypospadias. — Both  of  these  deformities  can  be 
readily  diagnosed.  In  epispadias  there  in  an  imperfect  formation  of  the 
upper  wall  of  the  urethra  (Fig.  222).  There  are  three  forms:  (a)  One 
in  which  only  the  glans  penis  is  involved.  This  is  so  rare  that  only  three 
genuine  cases  have  been  described,  (b)  The  groove  extends  back  to  the 
middle  of  the  penis,  (c)  The  most  frequent  form.  This  form  is  usually 
associated  with  an  ectopia  of  the  bladder  and  a  defect  in  the  pubic 
symphysis  (Fig.  223).  The  penis  and  the  groove  on  its  upper  surface 
are  very  short  and  pass  directly  over  into  the  bladder  defect.  Hypo- 
spadias is  much  more  frequent  than  epispadias.  The  deformity  is  due 
to  a  defective  formation  of  the  lower  wall  of'the  urethra.  There  are  also 
three  forms :  (a)  The  gap  or  groove  involves  only  the  glans  penis  (hypo- 
spadia glandis).  (b)  The  groove  extends  back  as  far  as  the  beginning  of 
the  scrotum.  The  urethral  orifice  is  at  the  latter  point.  This  form  is 
less  frequent  than  the  first  named  and  is  called  the  penoscrotal  form. 
The  penis  is  usually  curved  down  and  laterally,  (c)  The  scrotum  is 
more  or  less  completely  divided  into  two  lateral  halves.  The  urethral 
opening  is  in  the  perineum  or  in  the  groove  between  the  divided  scrotum 
(perineoscrotal  form).  The  penis  is  very  short  and  bent  downward  and 
the  foreskin,  as  in  the  penoscrotal  form,  shows  a  wide  gap. 


38o 


THE   ABDOMEN. 


CONTUSION  AND  RUPTURE  OF  THE  URETHRA. 

This  condition  usually  follows  a  fall  upon  some  object  like  a  plank  or 
an  axle,  these  coming  in  direct  contact  with  the  perineum.  It  may  also 
follow  a  blow  or  kick  in  the  same  region,  or  the  perineum  may  be  torn 
as  a  result  of  a  fracture  of  the  pelvis.  The  urethra  at  the  bulbomembra- 
nous  junction  is  caught  between  the  unyielding  pubic  symphysis  and  the 
object  upon  which  the  patient  falls.  For  this  reason  the  tears  are  most 
often  located  at  this  point. 

The  probability  of  a  rupture  of  the  urethra  must  be  thought  of  in 

every  case  either  of  blunt  force  ap- 
plied to  the  perineum,  or  an  injury 
in  which  the  pelvis  is  crushed. 

The  cardinal  signs  from  which  a 
diagnosis  can  usually  be  made  are: 

1.  The  appearance  of  a  hema- 
toma or  of  a  swelling  in  the  peri- 
neum. 

2.  The  escape  of  blood  from  the 
meatus  either  with  or  independently 
of  urination.  If  it  occurs  with  the 
latter,  blood  escapes  before  urine 
begins  to  flow. 

3.  There  is  either  retention  of  or 
great  difficulty  in  urinating  and  the 
act  is  accompanied  by  great  pain  in 
the  perineum  and  at  the  end  of  the 
penis.  The  urine  contains  coagu- 
lated and  fluid  blood. 

4.  Urinary  infiltration  of  the  sub- 
cutaneous tissues,  penis,  scrotum, 
and  anterior  abdominal  wall.  This 
causes   marked   swellings,   redness, 

and  tenderness  of  the  corresponding  parts,  and  may  be  followed  by 
severe  septic  infection  or  even  gangrene.  Such  extravasation  may  occur 
immediately  after  the  accident  or  graduafly  in  the  course  of  a  few  days. 
In  the  milder  cases  of  rupture  of  the  urethra  there  is  but  httle  bleeding 
from  the  meatus,  the  urine  is  almost  clear,  and  there  is  only  a  slight 
amount  of  perineal  swelling. 

The  diagnosis  of  the  more  severe  forms  depends  upon  the  observa- 
tion of  the  large  amount  of  blood  from  the  meatus,  the  perineal  hematoma, 


Fig.  224. — Enormous  Elephantiasis  of  the 
Scrotum,  Following  Traumatic  Rupture 
OP  THE  Urethra. 

This  is  the  front  view  of  the  patient  shown  in 
Fig.  225. 


PUS    m   LOWER   PORTION   OF   MALE    GEXITO-URIXARY   TRACT. 


the  difficult  and  painful  micturition,  and  at  times  the  urinary  infiltration 
with  accompanying  sepsis. 

Traumatic  rupture  of  the  urethra  may  be  fohowed  by  strictures  and 
perineal  fistulee  (Fig.  225),  whose  diagnosis  is  the  same  as  that  of  the 
same  conditions  when  due  to  gonorrhea  (page  381).  If  a  patient  giyes 
the  history  of  a  fall  followed  by  difficulty  of  urination,  one  must  always 
think  of  a  stricture.  When  a  tear  of  the  urethra  coexists  with  a  rupture 
of  the  bladder  and  fracture  of  the  pehds,  as  in  one  of  my  cases,  the  diag- 
nosis is  very  difficult,  but 
can  usually  be  made  by  a 

careful  study  of  the  physi-  I 

cal  findings. 


LOCALIZATION  OF  PUS  IN 
THE  LOWER  PORTION 
OF  THE  MALE  GENITO- 
URINARY TRACT  (FIG. 

234). 

The  question  whether 
pus  and  detritus,  causing 
the  urine  to  be  turbid,  origi- 
nate in  the  anterior  or  pos- 
terior urethra  or  in  the  ap- 
pendages of  the  lower  urin- 
ary tract  can  be  answered  in 
one  of  the  following  ways : 

The  Two-glass  Test. — 
After  a  patient  has  held  his 
urine  for  some  considerable 
time — two  to  four  hours — he 
is  adyised  to  empty  some  of  the  urine  into  one  glass,  then  to  stop  and  to 
void  the  balance  of  the  urine  into  another  glass  (Thompson  test). 

In  a  general  way  it  can  then  be  stated  that,  if  only  the  first  portion  is 
turbid  or  shows  floating  shreds  or  flakes,  the  pus  comes  from  the  anterior 
urethra  alone.  If  both  portions  are  turbid  or  contain  shreds  or  flakes, 
the  posterior  urethra  is  necessarily  involycd  in  the  inflammatory  process. 
Pus  production  in  acute  gonorrhea  is  usually  so  profuse  that  the  first  and 
second  portions  will  be  rendered  turbid  even  if  the  affection  is  located  in 
the  anterior  urethra  only.  The  reason  for  this  is  that  the  posterior 
urethra  does  not  permit  the  accumulation  of  any  considerable  amount  of 
secretion  in  its  lumen,     x^t  the  very  moment  that  secretion  accumulates. 


Fig.  225. — Posterior  View  of  Patient  Shown  in  Fig. 

224.     Suffering  from  Enormous  Elephanti.\sis 

of  Scrotum. 

F,  Opening  of  perineal  fistula,  which  resulted  from 
traumatic  rupture  of  urethra  and  stricture  subsequent  to 
same. 


382  THE    ABDOMEN. 

it  flows  back  into  the  bladder.  In  this  way  the  secretion  becomes  mixed 
with  the  urine  contained  in  the  bladder. 

The  lirst  portion  of  urine  voided  flushes  out  the  anterior  urethra, 
carrying  off  the  adherent  pathologic  products.  Unless  secretion  flows 
back  from  the  posterior  urethra  into  the  bladder,  the  second  portion  of 
urine  will  appear  clear.  The  conclusion  to  be  dra^^^l  from  this  rather 
crude  test  must  be  subjected  to  the  following  criticism : 

A  ver}'  thick  secretion  originating  in  the  anterior  urethra  may  still 
adhere  to  the  mucousmembrane  after  the  first  portion  of  urine  has  passed. 
Thus  the  second  portion  may  also  contain  flakes  of  pus  that  originate  in 
the  anterior  urethra.  Again,  at  the  time  of  the  test  there  mav  be  ven,^ 
little  production  of  pus  in  the  posterior  urethra,  so  that  the  second  portion 
of  the  urine  appears  clear,  although  there  is  still  disease  in  the  posterior 
urethra.  The  two-glass  test  is  only  of  ^-alue  if  it  is  employed  repeatedly 
and  at  different  visits. 

The  principle  of  this  test  can  be  appHed  in  a  more  refined  manner  in 
the  following  way:  The  test  is  best  made  early  in  the  day.  After  the 
patient  has  retained  his  urine  for  some  considerable  time,  the  an- 
terior urethra  is  washed  out  with  sterile  water,  either  by  using  a  soft- 
rubber  catheter  whose  tip  does  not  reach  beyond  the  spongy  portion  of 
the  urethra  or  by  applying  a  A^alentine  nozzle  without  overcoming  the  re- 
sistance of  the  compressor  urethras.  This  flushing  is  continued  until  the 
returning  fluid  appears  to  be  absolutely  clear.  Then  the  urine  is  voided; 
all  impurities  contained  in  this  specimen  necessarily  come  out  of  the 
posterior  part  of  the  urethra. 

Another  valuable  addition  to  this  method  is  as  follows :  If  it  is  desir- 
able to  gather  information  as  to  the  question  whether  secretion  comes 
from  the  prostate  or  the  seminal  vesicles,  the  anterior  urethra  is  first 
flushed  out  in  the  manner  described  above.  The  patient  should  then 
pass  half  of  the  contents  of  his  bladder.  The  index-finger  is  now  in- 
troduced into  the  rectum,  and  the  prostate  and  the  seminal  vesicles  are 
milked,  and  the  patient  then  voids  the  balance  of  his  urine. 

The  flushing  Hquid  used  for  the  irrigation  of  the  anterior  urethra 
contains  the  pathologic  products  of  this  portion.  The  first  portion  of 
the  urine  voided  contains  the  products  of  the  posterior  urethra.  The 
second  portion  of  the  urine  voided  contains  the  contents  of  the  prostate 
and  of  the  seminal  vesicles.  Pathologic  products  squeezed  out  of  the 
seminal  vesicles  have  a  characteristic  serpentine  or  twisted  shape. 

In  very  chronic  cases,  which  show  scant  secretion,  some  additional 
means  must  be  employed  in  order  to  find  the  seat  of  pathologic  products. 

In  order  to  stimulate  secretion  for  twenty-four  hours  previously  to 


PUS    IN   LOWER   PORTION    OF    MALE    GENITO-URINARY   TRACT.       ;iiii;^ 

executing  the  test,  irritating  irrigations  of  the  entire  urethra  are  admin- 
istered— I  to  10,000  bichlorid  solution  or  i  to  5,000  silver  nitrate  solution. 

At  the  same  time  the  patient  is  advised  to  drink  some  alcoholic 
beverage  the  evening  before  the  examination,  such  as  beer  or  cham- 
pagne. The  pathologic  products  from  infiltrated  portions  of  the  urethra 
are  collected  by  first  introducing  an  ohve-tipped  sound;  all  the  places  at 
which  the  sound  shows  some  engagement  are  squeezed  out  over  the 
olive  tip  by  two  fingers  massaging  the  urethra  from  the  outside. 

The  resulting  discharge  is  treated  in  the  manner  above  described. 
While  it  is  easy  and  simple  to  examine  specimens  of  the  discharge  micro- 
scopically as  to  their  structure,  the  search  for  gonococci,  particularly  in 
chronic  cases,  not  only  calls  for  frequent  examinations  of  numerous 
specimens,  but  even  then  may  be  negative. 

In  all  doubtful  cases  the  culture  test  for  gonococci  should  be  employed. 

Instrumental  Examination. — In  all  acute  inflammatory  processes 
of  the  urethra  instrumental  examination  is  contraindicated.  The  most 
convenient  instrument  for  endourethral  examination  is  the  elastic  bulb- 
ous bougie,  Guyon's  "explorateur  a  boule  olivaire"  or  bougie  a  boule. 
The  bougie  a  boule  carries  on  its  slender  shaft  an  olive-shaped  head 
which  is  conical  at  its  digital  end  and  sharply  cut  off  at  its  proximal  end. 
The  olive,  of  the  most  frequently  used  bougies,  has  a  diameter  of  18  to 
20,  French  scale;  it  is  well  to  have  a  whole  set,  these  bougies  ranging  in 
size  from  8  to  26.  In  the  normal  urethra  the  bougie  passes  the  anterior 
part  smoothly  and  without  any  resistance;  at  the  isthmus  the  head  en- 
counters a  slight  obstruction;  on  passing  it  the  patient  becomes  sensitive 
to  the  touch.  In  the  whole  length  of  the  membranous  urethra  the  bougie 
moves  slightly  engaged;  in  the  prostate  it  glides  easily  until  we  get  to 
the  internal  orifice,  where  we  feel  a  slight  interference  just  before  it 
enters  the  bladder.  In  some  cases  the  bougie  may  also  be  caught  in 
the  sinus  pocularis. 

While  passing  the  prostatic  urethra  the  patient  usually  has  a  desire 
to  urinate.  The  largest  diameter  of  the  head  of  the  bougie  being  at  its 
proximal  end,  the  obstructions  of  the  urethra  are  felt  more  distinctly  on 
retracting  than  when  the  bougie  is  introduced.  The  meatus  is  often  so 
narrow  that  we  have  to  cut  it  for  some  distance  before  making  an  exami- 
nation. The  bulbous  urethra  is  occasionally  very  wide  in  the  young  and 
often  in  the  old,  and  catches  the  end  of  an  inelastic  instrument  as  though 
it  were  in  a  blind  pouch.  This  obstruction  may  be  overcome  by  stretch- 
ing the  penis.  Right  behind  the  bulb  is  the  isthmus,  which  is  usually 
easy  to  pass,  except  in  ner^•ous  individuals,  in  whom  the  membranous 
urethra  is  generally  hyperemic,  and  we  get  reflex  spasmodic  contrac- 


384  THE    ABDOMEN. 

tion  of  the  compressor  urethrse.  Patience  and  perhaps  a  few  drops 
of  cocaine  solution  will  overcome  this  obstruction.  Any  obstructions 
in  the  course  of  the  urethra,  except  those  named  above,  are  patho- 
logic. In  strictures  we  feel  friction  and  unevenness;  it  feels  as  if  the 
bougie  jumped  over  a  hard  string.  If  a  stricture  which  is  too 
narrow  for  the  bougie  to  pass  has  been  found,  then  fihform  bougies 
are  resorted  to,  starting  with  the  smallest  number  and  gradually 
increasing  to  larger  ones  until  the  diameter  of  the  stricture  is 
found.  ]\Iany  strictures  are  sharply  hmited  and  stand  out  prominently 
from  the  healthy  or  less  infiltrated  surrounding  mucous  membrane  of 
the  urethra,  and  a  filiform  bougie  introduced  is  just  as  likely  to  be  caught 
in  a  pocket  of  the  mucous  membrane  as  to  enter  the  narrow  passage  of 
the  stricture  somewhere  in  the  middle.  It  is,  therefore,  a  good  plan  not 
to  try  to  pass  the  stricture  with  the  first  bougie  introduced;  if  it  catches 
in  a  pocket,  introduce  the  second  bougie,  and  so  on  until  either  all  of 
the  blind  pockets  are  filled  out  with  the  bulb  of  the  bougie  or  until  one 
accidentally  enters  the  stricture. 

We  can  use  conical  or  cylindrical  metal  sounds  instead  of  the 
bougie,  but  they  will  not  give  as  much  information  as  the  bougie.  In- 
filtrations due  to  chronic  gonorrhea  are  detected  by  having  the  sound 
in  the  urethra  and  palpating  with  the  hand  on  the  surface.  The  mem- 
branous and  prostatic  urethrse  can  be  palpated  through  the  rectum. 

From  the  foregoing,  it  is  clear  that  the  introduction  of  a  bougie  into 
the  urethra  not  only  permits  us  to  find  out  the  degree  of  sensitiveness 
and  smoothness  or  unevenness  of  the  urethral  mucous  membrane,  but 
it  also  gives  direct  means  to  determine  the  length  of  the  urethra.  ^Most 
convenient  for  this  purpose  are  Kutner's  graduated  bougies. 

The  diameter  of  the  urethra  in  its  different  parts  can  accurately  be 
measured  with  the  end  of  the  urethromcter.  The  oldest  and  most 
frequently  employed  is  that  of  Otis.  Of  newer  date  is  the  urethromc- 
ter of  Kollmann;  the  latter,  in  addition,  can  be  used  as  a  dilator  for  short 
distance. 

Urethroscopy. — The  pathologic  changes  in  a  large  percentage  of 
cases  of  chronic  gonorrhea  consist  in  widespread  infiltrations  of  slight 
degree,  but  nevertheless  they  may  cause  serious  disturbances.  In  other 
cases  the  pathologic  changes  are  confined  to  small,  inflamed,  suppurating 
conglomerations  of  glands  or  crypts  of  ]Morgagni,  which,  in  spite  of  their 
small  size,  are  the  carriers  of  virulent  infection  and  the  cause  of  constant 
discharge  of  pus.  On  the  other  hand,  it  is  not  necessary  that  they  betray 
their  presence  by  any  apparent  symptoms.  There  is  no  secretion  and  the 
urine  does  not  contain  any  filaments  for  weeks,  months,  or  even  years. 


PHIMOSIS — PARAPHIMOSIS — BALANITIS.  385 

Suddenly  the  patient  is  attacked  by  an  acute  gonorrhea  without 
having  exposed  himself  to  infection.  Such  cases  are  not  rare  in  every- 
day practice.  The  endourethral  examination  with  the  bulbous  bougie, 
the  sound,  and  the  urethrometer,  while  otherwise  of  great  service  in 
making  a  diagnosis,  will  give  little  information  in  these  cases;  they  re- 
main, therefore,  a  mystery  to  the  insufficiently  equipped  physician,  and 
this  is  what  gives  chronic  gonorrhea  the  name  of  being  incurable.  We 
must  first  make  a  correct  diagnosis  before  we  can  successfully  treat  a 
disease.  The  most  important  instrument  with  which  to  make  a  thorough 
examination  is  the  urethroscope. 

PHIMOSIS. 

This  is  an  abnormal  narrowing  of  the  foreskin,  so  that  it  cannot  be 
retracted  to  expose  the  glans.  It  is  most  often  a  congenital  condition, 
but  may  be  acquired  as  the  result  of  gonorrheal  inflammation  or  chan- 
croidal ulceration  beneath  the  prepuce. 

The  chief  interest  from  a  diagnostic  point  of  view  is  in  the  results  of 
the  phimosis.  These  are:  (a)  Recurrent  attacks  of  balanitis  from  ac- 
cumulation of  smegma,  (b)  Prolapse  of  the  rectum  or  a  hernial  pro- 
trusion as  the  result  of  straining,  (c)  Formation  of  preputial  calculi. 
(d)  It  favors  the  development  of  an  epithelioma  through  irritation  of  the 
secretions. 

PARAPHIMOSIS. 

Whenever  a  tight  foreskin  has  been  drawn  back  over  the  glans  penis 
and  is  not  allowed  to  slip  forward  again,  a  paraphimosis  results.  This  is 
due  to  the  formation  of  a  contraction  ring  in  the  retracted  foreskin  which 
prevents  the  blood  from  returning  toward  the  root  of  the  penis,  causing 
marked  swelling.  The  condition  can  be  readily  recognized  from  this 
swelling,  which  lies  just  behind  the  corona  glandis  and  is  separated  from 
the  main  body  of  the  penis  by  a  deep  groove  corresponding  to  the  con- 
traction ring.  The  longer  the  paraphimosis  lasts,  the  more  swelhng,  so 
that  the  groove  or  contraction  ring  may  be  entirely  hidden.  It  may  be 
followed  by  gangrene  of  the  foreskin. 

BALANITIS. 

This  is  the  result  of  an  infection  of  the  inner  or  mucous  layer  of  the 

prepuce.     The  entire  prepuce  is  swollen  and  tender  so  that  it  can  only 

be  retracted  with  difficulty.     The  glans  penis  and  inner  layer  of  the 

prepuce  are  both  reddened  and  ulcerated,  and  a  foul  purulent  discharge 


386 


THE    ABDOMEN. 


is  present.  The  retention  of  secretion  may  lead  to  deep  ulceration  and 
gangrene  of  the  prepuce.  This  condition  is  at  times  the  first  sign  of 
the  presence  of  a  diabetes. 


EPITHELIOMA  OF  THE  PENIS. 
This  occurs  late  in  life.     It  occurs  usually  in  one  of  two  forms,  either 
as  a  cauhflowerdike  growth  (Fig.  226)  or  as  an  ulceration  with  under- 
mined    and     markedly     indurated 
edges.      The    former   is    the   more 
frequent.     If  it  is  present  wath  a 
'  tight  prepuce  the  diagnosis  may  be 

made  from  the  purulent  discharge, 
:  by  palpating  the  induration  through 

the  intact  prepuce,  and  by  the  in- 
durated, enlarged  inguinal  lymph- 
nodes.  A  httle  later,  when  the  tumor 
has  penetrated  the  prepuce,  the 
diagnosis  is  much  easier.  The  dis- 
charge may  be  the  first  symptom 
which  calls  the  patient's  attention  to 
his  condition. 

The  second  or  ulcerative  form  re- 
sembles somewhat  the  carcinomata 
of  the  hp  with  their  craterdike  ulcer- 
ation, indurated  bases,  and  edges. 

In  the  differential  diagnosis  0}  the 
cauliflower  form  one  must  consider 
venereal  warts.  These  are  softer 
and  there  is  no  induration  of  the 
base  or  of  the  inguinal  lymph-nodes. 
From  the  ulcerative  form  one  must 
differentiate  a  chancre  and  a  gum- 
ma. In  neither  of  these  are  the 
edges  or  base  as  hard  as  in  carcin- 
In  chancre  there  may  be  enlargement  of  the  inguinal  nodes, 
but  they  are  never  as  indurated,  and  the  primary  lesion  is  followed  by 
other  secondary  symptoms  within  a  few  weeks.  If  any  doubt  exists, 
the  administration  of  antisyphilitic  remedies  will  soon  clear  up  a 
chancre. 

In  the  case  of  a  gumma  of  the  penis  the  same  clinical  findings  hold 


Fig.  226. — Typical  I'apillary  Carcinoma  of 
Prepuce  Perforating  Outer  Layer  .  of 
Same. 


oma. 


THE    TESTIS — ABNORMALITIES    IN    DEVELOPMENT. 


387 


true.     The  edges  or  base  are  never  as  indurated,  there  are  no  enlarged 
inguinal  nodes,  and  there  is  usually  the  history  of  syphilis  or  evidence  of 
its  presence  elsewhere.    The  administration  of  potassium  iodid  should 
cause   a  marked   differ- 
ence  in  the  appearance 
of  the  ulceration  within  a 
week. 


The  Testes. 

abnormalities  in  de- 
velopment. 

A  lack  of  develop- 
ment of  the  testis  may 
occur  in  an  imperfectly 
or  in  a  perfectly  de- 
scended testis.  It  is 
more  frequently  associ- 
ated with  the  former, 
but  it  must  not  be  as- 
sumed that  every  testis 
which  has  not  reached 
the  scrotum  is  incapable 
of  producing  healthy 
spermatozoa.  The  latter 
property  is,  however, 
lacking  in  the  majority 
of  such  cases. 

Such  non-developed 
testes  may  not  show  any 
perceptible  decrease  in 
size,  but  usually  they  are 

much  smaller  than  the  normal  organ.  One  can  recognize  such 
non-development  clinically  by  the  absence  of  many  of  the  male 
characteristics,  the  lack  of  pubic  hair,  the  infantile  size  of  the  penis 
and  scrotum  (Fig.  227),  the  smooth,  soft,  child-hkc,  hairless  skin  and 
fat  of  the  entire  body.  In  some  cases  this  so-called  infantilism 
is  accompanied  by  a  high-pitched,  almost  feminine  voice,  and  in  the 
case  shown  in  Fig.  227  there  was  a  lack  of  mental  development.  The 
term  "atrophy  of  the  testis"  should  be  confined  to  those  cases  in  which 
the  organ  has  been  normally  developed,  but  has  undergone  retrograde 


Fig.  227. — Infantilism  in  a  Patient,  Thirty  Years  of  Age, 
Due  to  Non-development  of  Testes,  with  Normal  De- 
scent OF  these  Organs. 


388 


THE    ABDOMEN. 


changes,  as  may  occur  after  acute  inflammations,  such  as  the  orchitis  fol- 
lowing mumps  or  injuries.  Occasionally  such  atrophy  may  take  place 
after  operations  for  inguinal  hernia,  or  in  a  moderate  degree  as  a  result 
of  a  marked  varicocele  of  long  standing. 


IMPERFECT    DESCENT    OF    THE   TESTIS   AND   ITS   COMPLICATIONS. 

If  the  testis  is  arrested  in  its  migration  from  the  abdominal  cavity 
to  the  scrotum,  the  condition  is  called  non-descent  or  retention  of  the 
testis.     If  it  has  pressed  through  the  inguinal  canal  and  then  assumes  an 

abnormal  position,  it  is 
called  an  ectopia  or  ab- 
normal descent. 

In  the  case  of  the  re- 
tained testis  the  organ  may 
be  arrested  (a)  within  the 
abdomen,  {h)  in  the  ingui- 
nal canal  (Fig.  228),  and 
jM||  2         o   ^  Wg\        (^)  J^^^  below  the  external 

^^^  ^      j^  JH        abdominal  ring  (Fig.  228). 

^^^  ^     fi  ^'  IPH        In  ectopia  testis  the  organ 

has    been    found    beneath 
the    skin    of   the   anterior 
abdominal    wall,    in     the 
femoral  region  (Fig.  229), 
in  the  perineum  (Fig.  230), 
at  the  root  of  the  penis  or 
toward  the  anterior  supe- 
rior spine  of  the  ilium. 
In    examining   a    child 
for  a  retained  testis,  it  must  be  remembered  that  children  possess  the 
ability  to  draw  the  testis,  even  when  normally  descended,  into  the  ingui- 
nal canal  almost  as  far  as  the  internal  ring  (Fig.  231). 

The  presence  of  a  retained  or  abnormally  descended  testis  may  be 
readily  recognized  by  first  palpating  the  scrotum,  when  one  or  both  sides 
will  be  found  empty.  Careful  search  should  then  be  made,  in  the  places 
where  the  testes  are  usually  retained  or  abnormally  placed,  for  a  soft, 
oval,  easily  movable  tumor  corresponding  to  the  testis.  In  children  the 
organs  may  be  retained  in  the  inguinal  canal  until  near  puberty  and  then 
suddenly  descend.  An  abnormally  retained  testis  cannot  be  palpated, 
and  the  first  sign  of  its  presence  may  be  an  inflammation. 


Fig.  228. — Most  Frequent  Locations  of  Testis  in  Cases 
OF  Non-descent. 
I,  Location  of  testis  within  inguinal  canal;  2,  location  just 
outside  of  external  abdominal  ring.     The  third  most  frequent 
position  (abdominal  testis)  is  not  shown  in  the  picture. 


IMPERFECT  DESCENT  OF  TESTIS  AXD  COMPLICATIONS. 


389 


The  following  conditions  may  develop  in  or  accompany  a  retained 
or  abnormally  descended  testis : 

Inflammation. 

Torsion  of  the  cord  (Fig.  232). 

Tumor  formation. 

Hydrocele  and  hernia. 

Inflammation.— This  is  especially  apt  to  occur  in  an  imper- 
fectly descended  testis,  often  from  torsion  of  the  cord.  The  situation 
of  the  local  inflammatory  signs  (pain,  swelling,  etc.)  varies  according 
to  the  location  of  the  organ.     The  pain  is  more  intense  than  in  intlam- 


■"Tn-y" 


rm'i''  y/f'   "^ 


% 


Fjg.  229.— Location  of  Testis  es;  Femoral  Region  (Eccles). 
The  testis  is  arrested  over  Scarpa's  triangle;    the  left  side  of  the  scrotum  is  atrophied. 


mation  of  the  normally  placed  organ,  and  is  apt  to  be  accompanied  by 
nausea  and  vomiting  greatly  resembling  a  strangulated  hernia  or  an  in- 
flamed lymph-node  if  located  in  the  femoral  or  inguinal  regions,  If 
situated  within  the  abdomen  the  condition  may  resemble  an  appendicitis 
or  some  other  acute  abdominal  condition. 

In  inflammation  there  is  an  absence  of  the  testis  in  the  scrotum  on 
the  affected  side,  the  onset  is  not  as  sudden,  nor  do  the  nausea,  vomiting, 
or  constipation,  if  present,  persist  as  they  do  in  strangulation.  The 
local  tenderness  and  swelling  are  also  more  marked  in  an  inflamed  testis 
and  there  is  more  apt  to  be  fever  and  leukocytosis  early. 

From  an    inflamed    lymph-node  the  diagnosis  is  not  as  difficult. 


39° 


THE    ABDOMEN. 


There  is  usualh'  some  primary  focus  for  the  enlarged  node  to  be  fomid, 
the  testis  is  present  on  the  inflamed  side,  and  the  sweUing  is  more  super- 
ficial than    in  an  in- 
flamed testis. 

2.  This  has  been 
discussed  on  page  274. 

3.  Tumor  For- 
mation,— It  has  been 
commonly  believed 
that  tumors  were  more 
likely  to  develop  in  an 
imperfectly  descended 
testis,  but  Eccles,  who 
has  examined  854 
cases  of  this  condition, 
believes  that  malig- 
nant disease  is  not 
more  frequent  than 
in  the  normally  de- 
scended organ. 

It  is  well  to  remember  that  a  gradual  enlargement  of  an  inguinal 
tumor,  if  the  testis  on  the  same  side  has  not  descended  into  the  scrotum. 


Fig.  230. — Left  Testis  in  Perineum  of  an  Infant  (Eccies). 


T          T 


Fig.  231. — Normal  Power  of  the  Cremaster  Muscles  in  Children  of  Drawing  Testis   through 

ExTEEN.^L  Abdominal  Ring  into  Inguinal  Canal. 

T,  Testes  outlined  on  surface  of  both,  showing  how  they  were  drawn  up  from  the  scrotum  in  a  boy  of  seven, 

as  far  as  the  e.xtemal  abdominal  ring.     The  small  size  of  the  scrotum  is  due  to  the  absence  of  both  testes. 


INFECTIONS    OF   THE    MALE   REPRODUCTIVE    ORGANS. 


39^ 


must  be  regarded  with  suspicion.     The  first  sign  of  its  malignant  char- 
acter may  be  the  evidence  of  a  distant  bone  metastasis. 

Hernia  and  Hydrocele  in  Connection  with  Imperfect  Descent.— 

Hernia  occurs  in  about  one-half  of  the  cases  of  undescended  testis  and 
is   most    often  of   the  con- 
genital    inguinal     variety. 
Hydrocele  is  also  a  frequent 
accompaniment. 


INFECTIONS  OF  THE  MALE 
REPRODUCTIVE  ORGANS. 

For  diagnostic  purposes 
it  will  be  found  of  service  to 
include  the  diseases  of  the 
vas  deferens,  seminal  vesi- 
cles, and  prostate  with  those 
of  the  testis  and  epididymis, 
since  in  many  of  the  cases 
of  pathologic  conditions 
of  these  latter  there  are  co- 
existing changes  in  the  three 
first-named  structures. 
This  is  especially  true  of 
gonorrhea  (page  382)  and 
tuberculosis. 

One  of  the  most  impor- 
tant lessons  to  learn  before 
attempting  to  make  a  diag- 
nosis of  these  conditions  is 
to  practise  palpation  of  the 

same  structures  either  on  the  non-affected  side  or  in  normal  individuals. 
A  physician  must  accustom  himself  to  the  consistency  and  relations  to  each 
other,  of  the  body  of  the  testis  or  orchis  proper,  and  of  the  epididymis. 
In  the  latter  one  must  learn  to  distinguish  the  head  or  upper  pole  from 
the  tail  or  lower  pole. 

The  vas  deferens  should  also  be  palpated  and  followed  toward  the 

external  abdominal  ring.     By  rectal  examination  the  normal  prostate 

may  be  palpated.     The  seminal  vesicles  cannot  be  felt  unless  enlarged. 

The  best  position  for  an  examination  of  the  testis  and  epididymis  is  to 

palpate  the  organs  of  the  right  side  with  the  left,  and  vice  versa  (Fig.  233). 


Fig.   232.- 


-Strangulation  of  a  Testis  Due  to  Torsion 
OF  ITS  Cord  (Eccles). 
The  darker  patches  indicate  extravasation  of   blood  into 
its  substance.     This  condition  was  present  in  a  case  of  non- 
descent  of  the  testis,  the  latter  being  arrested  in  the  inguinal 
canal. 


392  THE    ABDOilEX. 

The  chief  pathologic  conditions  of  these  structures  which  are  of 
clinical  interest  can  be  conveniently  divided  for  diagnostic  purposes  into 
two  classes,  as  follows : 

Acute  (Fig.  235).  Chronic  (Fig.  236). 

1.  Gonorrhea  most  often  involves  tlie  epi-     i.  Tuberculosis     in     early    stages    involves 

didymis  and  vas  deferens,  rarely  the  first    the    head    of    the    epididymis, 

body.  later  the    entire  epididymis  and  vas. 

Rarely  does  it  begin  acutely  or  as- 

2.  Trauma  usually  causes  enlargement  of  sociated    with    gonorrheal    epididy- 

body  of  testis  or  orchis  proper,  rare-  mitis. 
ly  of  the  epididymis. 

2.  Syphilis  in  majoritj-  of  cases  involves  body 

3.  Enlargement    joUo'u.'ing   epidemic   para-  or  orchis  proper.     Epididymis  rare- 

titis  {mumps)  always  involves  body  ly  involved  alone  or  in  conjunction 

of  testis  or  orchis  proper.  with  orchitis.     Gumma  of  vas  de- 

ferens quite  rare. 

4.  Cystitis  of  non-gonorrheal  origin  may  he 

followed    by    an    epididymitis    (es-       3.  JYeo^/a5;Hj,  whether  benign  or  malignant, 
pecially  with  enlarged  prostate).  always  begin  in  the  orchis  proper  or 


bodv  of  testis. 


Typhoid   and  influenza  rarely  are  fol- 
lowed by  an  epididymitis. 


The  above  table  holds  true  for  the  majority  of  cases.  Cases  will  be 
met  with,  however,  in  which  a  tuberculosis  may  begin  ver\'  acutely  or 
develop  upon  an  acute  gonorrheal  epididAinitis,  or  the  exceptional  cases 
referred  to  under  syphilis  may  occur.  In  general,  however,  such  a  table 
will  be  found  a  convenient  guide. 

The  principal  diagnostic  features  of  these  various  affections  follow\ 

Gonorrheal  Epididymitis  and  Orchitis. — This  occurs  in  the  second 
or  third  week  of  an  acute  attack  or  in  the  course  of  a  chronic  case  after 
the  passage  of  sounds  or  massage  of  the  prostate. 

The  epididymis  is  greatly  and  uniformly  enlarged  and  tender.  The 
structure  rests  like  a  cap  upon  the  orchis,  and  the  latter  can  be  distinctly 
felt  unless  an  acute  gonorrheal  hydrocele  (periorchitis  serosa  acuta) 
coexists;  then  a  double  enlargement  with  a  depression  between  is  to  be 
felt  (Fig.  235).  The  existence  of  an  acute  urethritis,  in  the  pus  of  which 
the  gonococcus  can  be  demonstrated,  confirms  the  diagnosis.  The  tem- 
perature varies  from  101°  to  104°  F.  The  vas  deferens  is  greatly  enlarged 
and  very  tender.  The  disease  may  occasionally  begin  with  severe  pain 
along  the  intra-abdominal  portion  of  the  vas  deferens.  When  an  epi- 
didymitis sets  in,  the  urethral  discharge  usually  ceases  temporarily.  The 
epidid}TTiis  remains  enlarged  and  tender  at  times  for  months  after  an 
attack.     Abscesses  may  form,  especially  after  a  gonorrheal  orchitis. 

Less  often  is  the  orchis  or  body  of  the  testis  involved  in  a  gonorrheal 


TRAUMATIC    AFFECTIONS — TUBERCULOSIS. 


393 


inflammation.     One  can  then  feel  a  smooth,  oval,  tender,  scrotal  tumor, 
upon  which  the  epididymis  rests,  unless  an  acute  hydrocele  obscures  it. 

TRAUMATIC  AFFECTIONS. 

These  usually  affect  the  body  of  the  testis,  especially  after  a  kick  or 
blow  on  the  scrotum.  The  epididymis  or  vas  deferens  may  occasionally 
be  inflamed  after  heavy  hfting.  If  they  result  from  lifting  some  heavy 
object,  the  epididymis  may  be  most  involved.  The  diagnosis  can  be 
readily  made  from  the  history,  the  palpatory  findings,  and  the  exclusion 
of  gonorrheal  infection. 


Fig.  233. — Method  of  Examining  the  Vas  Deferens  on  Either  Side. 
The  examination  of  the  right  vas  deferens  or  veins  of  the  spermatic  can  be  best  carried  out  by  standing 
either  in  front  or  upon  the  right  side  of  the  patient,  and  grasping  the  structures  between  the  index-finger  and 
thumb  of  the  left  hand.     The  same  method  may  be  followed  in  the  examination  of  the  vas  deferens  for  sper- 
matic veins  on  the  left  side  by  grasping  it  between  the  right  thumb  and  index-finger. 


TUBERCULOSIS. 

This  disease  most  often  begins  in  a  slow,  insidious  manner.  A  num- 
ber of  cases  have,  however,  been  reported  of  a  very  acute  development, 
especially  in  children  and  young  adults.  The  author  has  reported  a 
typical  case  in  which  it  followed  an  acute  gonorrheal  epididymitis  without 
perceptible  interval. 

The  testis  is  usually  involved  at  a  later  period,  so  that  it  is  possible 
at  such  a  time  to  find  that  the  testis  and  the  epididymis  are  involved  to 
such  an  extent  as  to  feel  like  a  continuous  body  through  the  scrotum. 


394 


THE    ABDOMEN. 


Fig.  234. — Localization  of  Gonorrheal  Infection  in  the  male  Genito-urinary  Organs  (Semidia- 

grammatjc). 
K,  Parenchyma  of  kidney;  Py,  gonorrheal  pyelitis;  Ut,  gonorrheal  ureteritis;  the  arrow  points  the  direction 
in  which  the  infection  ascends  from  the  bladder  to  the  kidney;  B,  bladder  wall;  the  arrow  at  the  neck  of  the 
bladder  indicates  the  direction  of  the  infection  from  the  urethra  to  the  bladder  (gonorrheal  cystitis) ;  UP,  seat 
of  posterior  urethritis;  M,  infiltration  of  urethral  walls  at  bulbo-membranous  junction — most  frequent  seat  of 
gonorrheal  stricture;  UA,  anterior  urethra;  T,  triangular  ligament,  which  divides  the  urethra  into  the  anterior 
and  posterior  portions.  Os  symphysis  pubis,  from  which  triangular  ligament  is  suspended;  PA.  periurethral 
abscess;  B,  balano-posthitis;  Ty,  inflammation  of  Tyson's  gland;  P,  seat  of  prostatic  abscess,  pointing  toward 
the  perineum,  involving  bulging  of  the  anterior  wall  of  the  rectum;  R,  rectum;  the  arrow  shows  the  direction  in 
which  infection  occurs,  causing  a  gonorrheal  proctitis;  V — D,  seat  of  the  vas  deferentitis;  E,  seat  of  gonorrheal 
epididymitis;  Or,  orchis,  or  body  of  testis;  H,  seat  of  acute  gonorrheal  hydrocele;  Mu,  musculature  of  abdom- 
inal wall;  S,  seminal  vesicles,  the  seat  of  gonorrheal  vesiculitis;  the  arrow  shows  how  transmission  is  effected 
from  the  posterior  urethra  to  the  seminal  vesicles  and  vas  deferens,  from  the  latter  to  the  epididymis,  etc. 


TUBERCULOSIS. 


395 


c. 


Fk;.  23s. — Differential  Diagnosis  of  Acute  Enlargements  of  the  Testis  and  Epididymis. 

a.  Normal  testis,  b,  Gonorrheal  epididymitis  and  vas  deferentitis.  Note  the  marked  enlargement  of  the 
epididymis  and  spermatic  cord  as  compared  to  the  normal  structures,  and  how  the  epididymis  almost  encloses 
the  testis,  c.  Acute  gonorrheal  epididymitis,  deferentitis  and  acute  gonorrheal  hydrocele,  d,  Acute  orchitis 
following  trauma  of  the  testis,  and  the  characteristic  enlargement  of  the  body  of  the  testis  (orchis)  following 
mumps,  and  other  infectious  diseases. 


396 


THE   ABDOMEN. 


Fig.  236. — Differential  Diagnosis  of  the  Chronic  Enlargejients  of  the  Testis  and  EpiDiDVMrs. 
a,  Syphilis  of  testis.  This  is  one  of  the  two  forms  in  which  syphilis  affects  th-e  testis.  In  this  variety  both 
testis,  that  is,  the  body  of  the  testis  (orchis),  and  epididymis  are  enlarged.  (See  text.)  b,  Second  variety  of 
syphilitic  affection  of  the  testis.  In  this  form  the  orchis  or  body  of  the  testis  is  predominantly  enlarged,  giving 
rise  to  a  large  tumor,  syphilitic  orchitis,  or  sarcocele.  c,  Tuberculosis  of  the  testis.  This  illustration  shows  the 
most  frequent  localization  of  tuberculosis,  especially  in  its  early  stages,  involving  especially  the  tail  of  the 
testis  and  the  vas  deferens,  in  the  form  of  a  nodulated  enlargement  of  the  former,  and  a  beaded  one  of  the 
latter,  d,  Tumors  of  the  testis.  This  illustration  shows  how  tumors,  both  benign  and  malignant,  of  thetestis 
almost  exclusively  affect  the  body  of  the  testis. 


TUBERCULOSIS.  397 

The  disease  may  follow  trauma  as  well  as  gonorrheal  inflammation 
or  foci  of  tuberculosis  elsewhere.  A  search  for  all  of  these  should  be 
made  in  every  case. 

In  the  majority  of  cases  the  disease  begins  slowly.  One  or  more 
hard  nodules  can  be  felt  in  the  upper  part  of  the  epididymis,  so  that  it 
feels  very  irregular.  Later  a  similar  condition  of  the  entire  epididymis 
can  be  felt  and  the  vas  deferens  is  thickened  and  bead-like  on  palpation. 
Early  abscess  formation  and  formation  of  a  sinus  in  the  scrotal  skin,  with 
discharge  of  thick,  cheesy  pus,  speak  for  tuberculosis.     i\n  examina- 


^■■r^"  "                RTE        ""^iiBi' 

''^^' 

^m 

^^■^R^  :^^_„-                _^,..-^--PA 

^H 

^^B              "^^ 

1 

m     '  "^  "^ 

v^ 

"^'^ 

•    .Aj^i^I^BWlj^       ~ '**'^"'**^^ 

Fig.  237. — Complications  Following  Gonorrheal  Urethritis. 
PA,  Periurethral  abscess  grasped  between  the  thumb  and  index-finger;    S,  collection  of  serum  between 
periurethral, abscess  and  acute  gonorrheal  hydrocele  (H);    RTE,  inflamed  epididymis  of  right  testis:  LT,  left 
testis. 


tion  of  the  prostate  and  seminal  vesicles  will  show  hard  nodules  in 
many  cases.  If  the  disease  is  advanced,  tubercle  bacilli  may  be  demon- 
strated in  the  urine,  as  referred- to,  in  the  diagnosis  of  renal  tuberculosis. 
It  is  rarely  necessary  to  resort  to  a  tuberculin  test  and  reliance  can  seldom 
be  placed  upon  a  negative  result  after  the  use  of  tuberculin. 

Tuberculosis  must  be  differentiated  from  a  chronic  enlargement 
which  may  be  a  sequel  of  an  acute  epididymitis.  The  induration  of 
such  a  chronic  epididymitis  is  usually  diffuse  and  tender,  the  vas  is  smooth 
and  firm,  and  the  history  of  a  previous  acute  gonorrheal  attack  and  exam- 
ination of  the  urine,  will  clear  up  any  doubts.     In  those  cases  referred 


398 


THE   ABDOMEN. 


to  above,  in  which  the  tuberculous  condition  develops  directly  upon  a 
gonorrheal,  the  diagnosis  can  only  be  made  from  the  more  nodulated 
outline  in  tuberculosis,  and  similar  nodules  in  the  vas  and  prostate,  or 
by  the  discovery  of  the  tubercle  bacilli  in  the  urine  or  in  the  pus  of  a  sinus, 
if  one  exists. 

Syphihs  usually  affects  the  body  of  the  testis  and  but  rarely  the  epi- 
didymis. The  induration  is  not  nodulated  if  it  affects  the  epididymis, 
and  the  history  and  the  administration  of  potassium  iodid  will  render  a 
differentiation  possible. 


Fig.  238. — View  from  the  Front  of  Conditions  Illustrated  in  Fig.  237. 
The  limbs  of  the  patient  were  widely  separated  in  order  to  take  the  photograph.     PA,   Periurethral 
abscess;  S,   collection  of  serum  at  lowermost  portion  or  scrotum;   H,  acute  gonorrheal  hydrocele;   RT,  in- 
flamed right  epididymis;  LT,  inflamed  left  testis. 


SYPHILIS. 

A  gradual,  almost  painless  enlargement  of  the  body  of  one  or  both 
testes  occurs.  An  acute  onset  with  pain,  is  very  rare.  The  enlarged 
orchis  can  be  readily  felt  as  an  oval,  smooth,  painless  tumor  in  the  scro- 
tum. The  epididymis  and  vas  are  rarely  involved.  In  one  case,  in 
which  such  a  complication  occurred,  I  was  able  to  differentiate  it  from 
tuberculosis  by  the  absence  of  nodulation  and  the  more  diffuse  character 
of  the  induration,  as  well  as  the  history  and  the  absence  of  sinuses.  The 
existence  of  a  large  accompanying  hydrocele  may  at  times  obscure  the 
existence  of  a  syphilitic  orchitis  until  the  fluid  is  evacuated. 


NEOPLASMS    OF   THE    TESTIS.  399 

TUMORS  OF  THE  TESTIS  AND  EPIDIDYMIS. 

These  may  be  divided  into: 

Benign. — (a)  Spermatocele,     (b)  Adenoma  and  cystadenoma  testis, 
(c)  Dermoids  and  teratoma. 

Malignant. — {a)  Sarcoma.     (&)  Mixed  tumors. 


SPERMATOCELE. 

This  form  of  tumor,  which  is  really  a  retention  cyst  of  the  epididymis, 
can  be  felt  as  a  tumor  which  grows  slowly  to  the  size  of  an  adult  fist. 
The  tumor  either  shows  distinct  fluctuation  or  is  quite  tense.  It  can  be 
felt  as  either  separating  the  testis  proper  from  the  epididymis  or  it  feels 
like  a  hydrocele.  It  can  be  recognized  on  exploratory  puncture  as  a 
spermatocele  by  its  milky  contents,  which  contain  spermatozoa. 


NEOPLASMS  OF  THE  TESTIS. 

In  the  diagnosis  of  neoplasms  of  the  testis  two  questions  present 
themselves:  (i)  Is  the  enlargement  of  the  organ  a  neoplasm?  (2) 
What  is  the  nature  of  the  new-growth  ? 

In  answering  the  first  question,  it  is  necessary  to  first  determine  by 
palpation  whether  the  body  of  the  testis  or  the  epididymis  is  involved  or 
whether  the  enlargement  is  one  of  the  tunica  vaginahs,  e.  g.,  hydrocele, 
hematocele,  etc. 

If  the  enlargement  is  found  to  be  of  the  epididymis  alone,  the  question 
of  a  neoplasm  need  not  enter  into  consideration,  since  the  principal  en- 
largements of  this  structure  are  due  to  gonorrhea,  syphilis,  and  tubercu- 
losis (see  page  392).  If  the  enlargement  is  of  the  body  of  the  testis  the 
chief  condition  to  be  differentiated  from  a  neoplasm  is  syphihs.  In  cases 
where  there  is  a  clear  history  of  this  latter  condition  the  diagnosis  will 
present  no  diihculties.  The  syphihtic  enlargements  are  more  stationary, 
showing  but  httle  tendency  to  an  increase  in  size.  The  only  variety  of 
neoplasm  which  causes  such  a  gradual  enlargement  of  the  testis  is  the 
benign  adenocystoma,  but  even  in  this  form  the  increase  in  size  is  more 
progressive  than  in  syphihs.  The  patients  will  usually  give  the  history 
of  a  more  rapid  enlargement  than  in  the  case  of  syphihs.  The  admin- 
istration of  potassium  iodid  for  a  week  will  usually  clear  up  the  diag- 
nosis in  those  cases  in  which  the  history  is  not  clear  and  there  arc  no  other 
evidences  of  syphilis  to  be  found  in  the  body.  A  malignant  neoplasm 
of  the  testis  can  be  readily  distinguished  from  syphilis  by  its  rapid 
growth. 


400  THE    ABDOMEN. 

A  hydrocele  can  be  differentiated  by  the  absence  of  enlargement  of 
the  body  of  the  testis,  by  the  translucency  test  (Fig.  239),  and  by  the 
use  of  the  aspirator  or  trocar  for  the  withdrawal  of  some  of  the  hydro- 
cele fluid. 

At  times  it  is  almost  impossible  to  difl"erentiate  a  hematocele  from  a 
neoplasm  of  the  testis.  In  the  latter  the  tumor  is  heavier  and  there  is  an 
absence  of  inflammation  and  of  syphilis,  the  latter  being  the  most  fre- 
quent cause  of  a  hematocele,  also  called  periorchitis  hemorrhagica. 

The  second  question  to  be  answered  is,  What  is  the  nature  of  the 
neoplasm  ?  Tumors  of  the  testis  may  be  divided  into  two  great  groups — 
benign  and  malignant.  The  benign  are  the  adenocystomata,  which  are 
the  most  frequent,  and  the  rarer  forms,  such  as  dermoid  cysts.  Of  the 
latter  only  a  few  cases  have  been  reported.  The  malignant  varieties 
belong  either  to  the  sarcomata  proper  or  to  the  so-called  mixed  tumors 
recently  studied  by  Wilms.  The  majority  of  the  cases  of  sarcomata  of 
the  testis  belong  to  the  small  round- celled  or  spindle- celled  varieties. 
They  grow  very  rapidly,  often  appear  simultaneously  in  both  testes,  and 
spread  along  the  spermatic  cord  and  inguinal  lymph-nodes  to  the  retro- 
peritoneal nodes.  ^Metastases  appear  very  early.  The  mixed  tumors 
contain  muscle  fibers,  cartilage,  myxomatous  tissue,  glandular  acini, 
bone,  and  blood-vessels  in  var\'ing  proportions  and  combinations. 
Many  text-books  speak  of  cases  of  carcinoma,  but  their  existence  is 
denied  by  other  equally  good  authorities. 

Clinically,  the  only  distinction  between  the  benign  and  malign-ant  neo- 
plasms is  their  rate  of  growth.  The  malignant  varieties,  especially  the 
sarcomata,  cause  so  rapid  an  enlargement  of  the  body  of  the  testis  that 
a  diagnosis  can  be  readily  made.  Accompanying  this  increase  in  size 
there  is  involvement  of  the  spermatic  cord  and  inguinal  retroperitoneal 
lymph-nodes,  all  of  which  can  be  determined  by  palpation.  Sarcomata 
are  most  common  in  children  before  the  age  of  ten,  and  again  in  adults 
between  thirty  and  forty.  In  the  benign  varieties  of  neoplasms  of  the 
testis  the  oval  shape  of  the  testicle  is  preserved.  As  the  gradual  in- 
crease in  size  occurs  the  surface  becomes  nodulated  and  softer  in 
places. 

The  mixed  tumors  form  a  clinical  group  by  themselves.  They  cause, 
at  times,  a  gradual  enlargement  of  the  testis;  at  others,  a  ver}-  rapid  one. 
After  their  removal  they  are  most  apt  to  cause  metastases  in  the  lungs 
and  bones  (Fig.  408J. 


HERNIA. 


401 


Hernia. 

A  hernia  may  be  defined  as  the  abnormal  protrusion  of  a  visciis  jrom 
any  preformed  cavity  of  the  body.  The  term  is,  however,  Hmited  to 
those  protrusions  in  which  a  portion  of  the  abdominal  viscera  escapes 
through  openings  in  the  muscular  or  bony  wall. 

The  opening  through  which  a  hernia  escapes  is  called  the  hernial 
ring  or  rings  (if  there  are  two,  as  in  the  case  of  the  indirect  inguinal). 

The  most  frec^uent  varieties  of  hemi^e  are  the  inguinal  (73.4  per  cent.), 


Fig.  239. — Method  of  Determining  the  Tkansldcency  of  a  Scrotal  Tumor  in  Order  to  Make  a 
Diagnosis  of  Hydrocele  from  that  of  a  Solid  Tumor  of  the  Testis  or  from  a  Hernia. 
An  electric  lamp  or  candle  is  held  on  the  distal  side  of  the  tumor,  while  the  examiner  places  a  roll  of  paper 
or  a  cyUnder  against  the  scrotal  tumor  on  the  side  opposite  to  that  on  which  the  light  has  been  placed.     In  case 
of  a  hydrocele,  the  hght  is  readily  transmitted  through  it. 


the  femoral  (18  per  cent.),  and  the  umbilical  (8.47  per  cent.).  The  frac- 
tion remaining — i.  e.,  0.12  per  cent.  (Eccles) — represents  the  ventral, 
obturator,  sciatic,  lumbar,  perineal,  vaginal,  and  diaphragmatic  varieties 
in  the  order  named.  The  contents  of  a  hernial  sac  are  most  often  in- 
testines and  omentum.  Gurgling  and  tympany  speak  for  the  former, 
while  a  nodulated  surface  and  dullness  on  percussion  speak  for  the  latter 
(omentum). 

Among  rarer  contents  may  be  mentioned:     (a)  Ovary  (increases  in 
size  and  becomes  more  tender  during  menstruation) ;  (b)  testicle,  feel- 
26 


402 


THE    ABDOMEN. 


3w 


0  o 

H  O 

H  (« 

■<  W 


St3 


O   fl  ii 


1^1 


ni  ;r3   O     . 

cd    ^  OJ    bC 
O 


n; 

bb 

oT 

13 

o 

^    k 

tf) 

f^ 

c 

^ 

u 

o 

s 

bJD 

o 

(J 

_d" 

'3 

d   O 

u 
O 

0 

ni 

d 

c^ 

^ 

o 

-^^ 

«  a; 

-13 

In 

bD 

d  d 

d 

d 
o 

> 

rt 

OJ  J^ 

d  cd 

^ 

hJ 

PLH 

O 

P^ 

cq 

fe 

bc-^ 

d  .td 
•^  d 


;3    oj 


d    tjj 


U 


'^  ^  d 
t3        d  >-^ 

oJ  ^  =^  5  S 

b  >^  <"  ^  -^ 

2  o  <-i  s  T^ 


t:)  O 


S.2 


U      ^ 


o  a.;d.d 


bC       ^ 


6  . 

d 
o 
'Sb 

CJ 

rd 

bO 

d 
o 

U 

O- 
rt 

^ 

OJ 

s 

en 

s 

M  M 

•O    bfl 

.5 
'd 

d 
1— 1 

o 

u 

.s 

bi 

d 

o 
d 

o 

a. 

i2 

to 

^  d 

§ 

aj 
§ 

« 

« 

P 

% 

% 

p^ 

d 
.2 

'bO 

d 

S 

y  d 

_d  OJ 

"to  s 

8  S 
G  « 

Q  W 
WW 

"d 
>-< 

d 

u 

d 
o 

u 
•  S 

br 

d 

d   bD  d 
.add, 

(U    O 

s  s 

CO 

aj 
d 
o 

6 

d 
o 

w 

Q 

^ 

^ 

bb 

d 

^^ 

p 

(U 

a. 

is 

d 

CO 

1— 1 

►^    p^ 


d  d 

o 


ing  smooth,  firm,  and 
like  a  plum;  (c)  vermi- 
form appendix;  ((/)  urin- 
ary bladder;  [e]  uterus 
or  tubes;  (/)  Meckel's 
diverticulum  (Fig.  1 58) ; 
{g)  rarely  the  stomach, 
liver,  or  spleen. 

A  hernia  is  said  to 
be  reducible  when  its 
contents  can  be  returned 
into  the  abdominal  cav- 
ity upon  gentle  manipu- 
lation or  when  the  pa- 
tient lies  down.  It  is 
said  to  be  irreducible 
when  the  above  tests  re- 
sult negatively. 

The  following  com- 
plications of  both  redu- 
cible and  irreducible 
hemiae  may  occur.  They 
are  more  frequent  in  the 
irreducible  variety. 

1 .  The  lumen  of  the 
bowel  becomes  obstruct- 
ed from  within  through 
stagnation  of  feces.  This 
is  called  an  incarcerated 
or  obstructed  hernia. 

2.  The  sac  wall  or 
even  the  contents  (es- 
pecially omentum)  be- 
come acutely  inflamed 
from  causes  both  within 
and  external  to  the  sac. 
This  is  called  an  in- 
■flamed  hernia,  and  if 
it  occurs  in  the  redu- 
cible variety,  adhesions 
form  and  produce  irre- 
ducibilitv. 


HERNIA. 


403 


3.  Strangulated  hernia.  In  this  complication  there  is  interference 
with  the  passage  of  feces  through  the  intestinal  contents  and  secondary 
gangrene  of  the  bowel  wall  as  the  result  of  interference  with  the  circula- 
tion. 

Strangulation  most  often  follows  a  sudden  increase  in  abdominal 
pressure,  as  in  coughing,  lifting,  straining  at  stool,  etc. 


Fig.  240. — Location  of  Various  Forms  of  Abdominal  Herni.e  (Diagrammatic). 

U,  Umbilical  hernia;  D.  direct  inguinal  hernia;  B,  indirect  incomplete  inguinal  hernia;  O,  complete  or  scrotal 

inguinal  hernia;  F,  femoral  hernia. 


The  principal  diagnostic  points  of  reducible  and  irreducible  hemiae 
and  their  complications  are  given  in  the  table  on  page  402. 

It  is  very  difficult  to  differentiate  between  an  obstructed  and  a 
strangulated,  and,  again,  between  an  inflamed  and  a  strangulated,  hernia, 
since  acute  strangulation  may  occur  in  an  obstructed  hernia  and  the 
inflammation  may  spread  to  the  general  peritoneal  cavity  from  an  in- 
flamed hernia.  At  the  present  time  operation  is  indicated  in  ever}^ 
case  of  irreducible  hernia  accompanied  by  local  signs,  such  as  pain,  ten- 


404 


THE    ABDOMEN. 


demess,  and  constipation,  or  nausea  and  vomiting.  Hence  the  above 
differential  points  have  often  only  a  theoretic  value.  Emphasis  cannot 
be  too  strongly  laid  upon  the  danger  of  forced  taxis  in  the  efforts  to 
reduce  an  irreducible  hernia  for  the  purposes  of  diagnosis  or  treatment, 
whether  or  not  such  a  hernia  be  accompanied  by  signs  of  inflammation 
or  obstruction. 

In  the  table  on  page  402  attention  is  called  to  the  fact  that  strangula- 
tion of  only  a  portion  of  the  wall  of  the  gut  (acute  partial  enterocele  ^)  may 
occur,  causing  far  less  marked  symptoms  of  intestinal  obstruction  than 

if  the  whole  circumference  be 
strangulated.  The  same  atypi- 
cal clinical  picture  may  appear 
if  the  appendix  or,  as  rarely 
occurs,  a  Meckel's  diverticu- 
lum is  strangulated.  As  in 
acute  partial  enterocele,  the 
bowels  may  move  normally  or 
there  may  even  be  diarrhea. 
Here  locahzed  tenderness  over 
the  hernial  region  is  the  most 
valuable  sign.  Other  atypical 
forms  are:  fa)  When  strangu- 
lation occurs  within  the  sac  or 
(h)  w^here  it  takes  place  in  a 
multiloculated  sac.  In  both  of 
these  the  impulse  on  coughing 
may  be  retained. 

Again,  two  or  more  irredu- 
cible hemiae  may  coexist,  as  in 
the   case   sho\\Ti   in   Fig.   252 
(femoral  and  inguinalj .    It  is  then  difficult  to  say  which  has  been  strangu- 
lated.    But  in  all  of  these  anomalous  forms  the  local  tenderness  is  the 
most  important  symptom. 


^J' 


Fig.  241. — Left-sided     Congenital     Complete    In- 
guinal Hernia  in  a  Boy  of  Eight. 
Note  the  location  of  the  testis  at  the  lowermost  portion 
of  the  scrotum. 


INGUINAL  HERNIA. 
This  may  be  of  three  varieties : 

1.  Indirect  or  oblique. 

2.  Direct. 

3.  Interstitial. 

'  This  form  of  partial  strangulation  of  a  gut  has  also  been  called  a  Littre  hernia. 


INGUINAL    HERNIA. 


405 


I.  Indirect  or  Oblique  Inguinal  Hernia. — As  long  as  the  sac 
andjits  contents  remain  within  the  inguinal  canal  this  form  is  caUed 
an  incomplete  indirect  or  obhque  inguinal  hernia  or  bubonocele. 
When  the  sac  and  its  contents  protrude  through  the  external  ab- 
dominal ring  (Fig.  241)  into  the  scrotum,  it  is  called  a  complete  or 
scrotal  hernia. 

The  incomplete  form  may  be  recognized  as  a  swelling  which  causes 


Fig.  242. — Method  of  Invaginating  the  Scrotum  in  Order  to  Determine  the  Size  of  the  External 

Abdominal  Ring. 
When  examining  the  left  external  abdominal  ring,  as  in  the  illustration,  the  left  index  and  middle  fingers 
of  the  examiner  should  be  used.  This  can  best  be  done  when  the  patient  stands  upon  a  chair.  The  scrotum 
is  then  invaginated,  until  the  index-finger  feels  the  spine  of  the  pubis,  to  the  inner  side  of  which  the  oval 
opening  of  the  external  abdominal  ring,  which  in  adults  normally  admits  the  index-finger,  can  be  distinctly 
felt.  The  impulse  of  a  hernia  can  be  best  felt  in  this  manner.  The  patient  is  instructed  to  cough  while  the 
index-finger  is  placed  in  the  external  abdominal  ring. 


a  prominence  along  the  course  of  the  inguinal  canal  (from  the  internal 
to  the  external  abdominal  ring). 

The  swelling  has  all  of  the  characteristics  of  a  reducible  hernia,  viz., 
that  it  causes  a  swelling  in  a  hernial  region'  having  all  the  properties 
referred  to  on  page  402. 

There  is  a  distinct  impulse  to  be  felt  on  coughing  (Fig.  242).  The 
swelling  becomes  more  visibly  prominent  when  the  patient  coughs  or 
strains  or  stands  up.  It  can  be  caused  to  disappear  by  hght  taxis  or 
when  the  patient  lies  dovm.     The  impulse  is  often  best  felt  by  invaginat- 


4o6 


THE    ABDOMEN. 


ing  the  scrotum  and  inserting  the  index-iinger  (Fig.  242)  through  the  ex- 
ternal ring  into  the  canal. 

When  the  hernia  is  of  the  complete  or  scrotal  variety  the  position  of 
the  swelling  at  the  upper  end  of  one  side  of  the  scrotum,  passing  up 
into  the  groin  on  the  outer  side  of  the  pubic  spine,  is  typical.     It  can 
usually  be  readily  reduced  upon  lying  down  and  caused  to  reappear  when 
^  the  patient  coughs.    The 

size  of  the  external  ring 
varies  according  to  age, 
and  to  some  extent  in 
different  individuals.  In 
general,  it  admits  the  in- 
dex-finger in  adults  and 
the  little  finger  in  chil- 
dren. In  inguinal  hernias, 
especially  if  they  are  of 
long  standing,  the  ring 
will  often  admit  three  to 
four  finger-tips.  The  in- 
ternal ring  cannot  be 
felt.  If  the  hernia  has 
existed  for  many  years, 
the  external  and  internal 
rings  may  come  to  he  op- 
posite each  other,  so  that 
after  the  contents  are  re- 
duced, the  finger  inserted 
through  the  external  ring 
seems  to  sink  directly  to- 
ward the  peritoneal  cav- 
ity, there  being  no  pos- 
terior wall  to  the  canal. 
This  variety  is  called  a 
straight  hernia.  An  in- 
guinal hernia  may  be  so  large  that  no  trace  of  the  penis  is  to  be 
found  (Fig.  243). 

2.  Direct  Inguinal  Hernia. — A  direct  inguinal  hernia  appears  at 
the  outer  edge  of  the  rectus  and  is  usually  much  smaller  than  the  obhque 
form  and  more  rounded  (Fig.  240).  It  is  very  difficult  to  distinguish  it 
from  the  above  mentioned  straight  hernia,  having  the  same  palpatory 
findings  and  occurring,  like  it,  in  elderly  people.     It  is  almost  impossible 


Fig.  243. — Enormous  Double  Inguinal  Heeni..e. 
The  right  was  reducible,  but  the  left  was  irreducible.  The 
depression  in  the  center  of  the  scrotal  mass  shows  the  atrophy  of 
the  penis,  the  organ  being  entirely  hidden  in  cases  of  large  herniae. 
The  illustration  also  shows  an  enormous  layer  of  abdominal  fat, 
which  the  patient  was  able  to  pick  up  in  his  hands,  in  order  to 
have  the  hernia  photographed. 


INGUINAL   HERNIA.  407 

to  state  positively  that  the  hernia  is  a  direct  one  in  such  cases  until  at 
operation  the  deep  epigastric  artery  is  found  along  the  outer  border  of 
the  sac. 

3.  Interstitial  Hernia. — There  are  three  varieties  of  this  form  (Fig. 
246)  and  it  usually  accompanies  non-descent  of  the  testis.  The  first 
variety  is  that  in  which  the  sac  Hes  between  the  internal  and  external 
oblique  muscles.  This  variety  is  more  common  on  the  right  side  of  the 
body  and  causes  an  oval  swelling  parallel  to  and  directly  above  Pou- 
part's  hgament.     It  does  not  project  much  from  the  surface  and  some  of 


Fig.  244- — Typical  Appearance  of  a  Case  of  Left-sided  Complete  Oblique  Inguinal  Hernia. 
Note  the  depression  between  the  lower  border  of  the  hernia  and  the  upper  border  of  the  testis. 

the  sac  may  pass  into  the  scrotum  or  labium,  so  that  a  groove  appears 
between  the  two  parts  of  the  hernia. 

In  the  second  variety  the  sac  hes  between  the  external  oblique  apo- 
neurosis and  the  skin.  The  swelling  has  the  same  position  as  in  the  first 
form,  but  there  is  more  projection  from  the  surface. 

In  the  third  variety,  or  propcritoneal  hernia,  there  is  almost  always 
a  part  of  the  sac  in  the  labium  or  scrotum  (Eccles).  It  is  seldom  recog- 
nized except  when  strangulated  or  during  radical  cure  operation. 

Unusual  Contents  of  Inguinal  Herniae. — Hernia  of  the  Bladder.— 
This  occurs  oftencrin  connection  with  an  inguinal,  than  in  femoral  hernia. 


4o8 


THE    ABDOMEN. 


The  most  frequent  variety  is  where  the  peritoneum  covering  the  bladder 
forms  a  part  of  the  sac. 


Fig.  245. — Method  of  Palpating  the  Spermatic  Cord  ix  Order  to  Make  the  Diagkosis  of  Complete 
Oblique  Inguinal  Herxl\  aeter  Reduction  of  the  Contents  of  the  Sac.     (See  text.) 


Fig.  246. — Various  Forms  of  Interstitial  Herni.e. 

I,  Subaponeurotic;    2,  subcutaneous;   3,  properitoneal  (Eccles).     5,  Skin;   EO,  e.xternal  oblique  aponeurosis 

and  muscle;  10,  internal  oblique  muscle;  T,  transversalis  muscle;  P,  peritoneum. 


A  diagnosis  may  be  made  before  operation  if  the  patient  gives  the 
history  of  the  tumor  disappearing  during  micturition,  and  if  when  pres- 
sure is  made  over  it,  the  patient  experiences  a  desire  to  urinate,  or  if  the 


INGUINAL   HERNIA. 


409 


act  of  micturition  ceases  suddenly  and  begins  again  as  soon  as  the  hernial 
swelling  is  compressed. 

Vermiform  Appendix. — The  presence  of  this  structure  cannot  be  rec- 
ognized before  operation  unless  it  should  become  inflamed  or  strangu- 
lated.    The  symptoms  of 

the  latter  are  less  marked        |.        j  ,..>  J^ 

than  in  a  strangulation  of  '"v  <  M 

the  intestine  proper.  "  T\ 

Ovary. — Before  pub- 
erty its  presence  may  be 
suspected  if  an  oval,  firm, 
freely  movable  tumor  be 
found  in  the  inguinal  canal 
or  just  external  to  it. 
Later  in  life  the  ovary  can 
only  be  recognized  before 
operation  if  a  firm  body  is 
found  in  the  hernial  sac, 
which  swells  and  becomes 
quite  tender  during  men- 
struation. 

I.  Differential  Diag- 
nosis of  Inguinal  Hernia 

in   the  Male. — i.  When  Reducible  and  Complete. — (a)  From  femoral 
hernia  the  following  table  will  best  illustrate  the  chief  points  of  difference : 


Fig.  247. — Inguinal  Hernia  with  Undescended  Testis. 


Inguinal. 
Emerges  on  inner  side  of  pubic  spine. 
Inguinal  canal  filled  and  pubic  spine  ob- 
scured, when  descended. 
Easily  recur  after  reduction. 
Impulse  felt  above  Poupart's  ligament. 


Femoral. 

1.  Emerges  on  outer  side  of  spine. 

2.  Inguinal  canal  empty  and  pubic  spine  to 

be  felt. 

3.  Do  not  so  easily  recur. 

4.  Impulse  below  Poupart's  ligament. 


(b)  From  a  congenital  or  acquired  hydrocele  and  from  an  undescended 
testis  lying  just  outside  of  the  external  abdominal  ring. 

In  the  last  named  condition  the  testis  of  the  corresponding  side  is 
felt,  just  beneath  the  external  abdominal  ring  (Fig.  228),  as  a  firm  elastic 
body  a  httle  smaller  than  the  normal  testis.  There  is  no  impulse  on 
coughing  and  the  swelling  cannot  be  reduced.  Not  infrequently  a 
hernia  is  associated  with  this  condition,  so  that  a  swelling  is  felt  above 
the  testis,  which  emerges  from  the  inguinal  canal  on  coughing  and  dis- 
appears upon  manipulation  or  upon  lying  down. 

(c)  The  following  table  shows  the  differentiation  of  a    congenital 


41  o 


THE   ABDOMEN. 


hydrocele,  and  acquired  hydrocele  and  a  reducible  inguinal  hernia  (see 
Figs.  239,  245,  249) : 


CoiiPLETE  Inguinal 
Hernl4  (Reducible). 


coxgexital 
Hydrocele. 


Acquired  Hydrocele. 


I.  Location. 


2.  Impulse 

3.  Translucency 


4.  If  reduced. 


5.  Relation  to  testis 
and  cord 


6.  Palpation  and  per- 
cussion  


Swelling  continuous 
with  inguinal  region. 


Distinct  on  coughing. 

Not  translucent,  as  a 
rule.  Rarely  so,  in 
children  (Fig.  241). 

Feel  gurgling  if  con- 
tains intestine,  reap- 
pears rapidly  on 
coughing. 

Lies  above  or  in  front 
of  testis  (see  Fig. 
244)  and  in  front  of 
cord. 

Soft  semi-elastic;  dull 
if  omentum;  tjon- 
panitic  if  intestine. 


Same  as  in  hernia.  Swelling  terminates  at 
upper  end  of  scrotum, 
can  feel  cord  above  tu- 
mor (Fig.  250). 

Xo  impulse.  No  impulse. 

Translucent.  Translucent    (Fig.    239) 

unless     greatly     thick- 
ened sac. 

Reduction     ven,'    Cannot  be  reduced, 
slow.         Reap- 
pears slowly. 

Same  as  in  hernia.  Lies  in  intimate  relation 

j     to  testis,  latter  felt  usu- 

!     ally  below  and  behind 

tumor. 

Harder  and  more    Pear-shaped       swelling; 

tense;    dull    on      harder  and   tense;  dull 

percussion.  j     on  percussion. 


2.  When  Complete  and  Irreducible. — The  following  conditions  must 
be  considered  in  making  a  diagnosis: 

In  the  male: 

(a)  Hydrocele  of  the  tunica  vaginahs  (acquired  hydrocele). 

(b)  Hydrocele  of  the  cord  (encysted  hydrocele — Fig.  249). 

(c)  Hematocele. 

(d)  Enlargements  of  the  testis. 

In  the  female: 

(a)  Hydrocele  of  the  canal  of  Nuck. 

(b)  Hydrocele  of  the  hernial  sac. 

The  chief  differential  points  are  considered  in  the  accompanying 
table : 


CoiEPLETE  Irreducible 

Hydrocele  07  the. 

Enlargements  of 

Inguinal  Hernia 

Tunica  Vaglnalis. 

Testis. 

Inspection 

Tumor  e.xtends  through 

Tumor  terminates  be- 

Same   as    in    hy- 

external ring  into  in- 

low external  ring. 

drocele. 

guinal  canal. 

Palpation 

Expansile    impulse    on 

No     impulse.     Feels 

No  impulse. 

coughing.     Feels    soft 

tense  and  elastic. 

Firm,  may  be  ir- 

if intestine;    firmer  if 

regular. 

omentum. 

Percussion 

Tvmpanv,  if  intestine. 

Dullness. 

Dullness. 

Relation  to  testis 

Testis  is  below  and  be- 

Testis cannot  be  dis- 

Can   outline    en- 

hind tumor. 

tinctly  felt. 

largement        of 
body  or  epididy- 
mis. 

Translucencv 

Negative  except    rarelv 

Positive  unless  tunica 

Negative. 

in  young  children  (Fig. 

greatlv  thickened. 

239)- 

INGUINAL   HERNIA. 


411 


A  hematocele  gives  the  history  of  trauma  or  syphiHs,  and  is  not  trans- 
lucent. In  an  encysted  hydrocele  of  the  cord  one  can  often  palpate  the 
nodules  and  can  ascertain  their  attachment  to  the  cord. 

In  a  hydrocele  of  a  hernial  sac  the  tumor  can  be  caused  to  gradually 
disappear  by  gentle  manipulation  and  elevating  the  pelvis. 

2,  5. 


4. 


5. 


^-^[R 


viR. 


TV 


Fig.  24S. — Various  Forms  of  Hydrocele. 
IR,  Internal  abdominal  ring;    ER,  external  abdominal  ring;    T,  testis  and  epididymis,  shown  in  black. 

1.  Congenital  hydrocele.     The  cavity  of  the  hydrocele  sac  (H)  communicates  directly  with  the  peritoneal  cavity. 

2,  Typical  form  of  acquired  hydrocele:  H,  Distended  tunica  vaginalis.  3,  Acquired  inguinal  hernia  and  ac- 
quired hydrocele:  S,  Sac  of  hernia;  H,  hydrocele  sac.  4,  Hydrocele  of  funicular  process.  The  process  is 
closed  at  the  internal  abdominal  ring,  but  is  continuous  below  with  the  tunica  vaginalis:  P,  Represents  that 
portion  of  the  sac  lying  within  inguinal  canal.  5,  Hydrocele  of  cord:  EH  and  EH,  placed  respectively  within 
the  inguinal  canal  and  just  outside  of  the  external  ring,  represent  the  two  loculi  of  a  hydrocele  of  the,  cord ; 
TV,  normal  tunica  vaginalis.  6,  Hydrocele  o_f  a  hernial  sac.  AO,  .\dherent  omentum;  HF,  hydrocele  fluid 
in  lower  portion  of  sac. 

In  a  hydrocele  of  the  canal  of  Nuck,  which  is  quite  rare,  the  diagnosis 
can  only  be  made  if  there  is  distinct  absence  of  impulse. 

3.  When  Irreducible  and  Incomplete. — In  the  Male: 

(a)  From  a  retained  inguinal  testis. 

(6)  From  various  causes  of  enlargement  of  the  spermatic  cord  (en- 
cysted hydrocele,  lipoma). 


412 


THE    ABDOMEN". 


(c)  From  enlarged  and  inflamed  lymph-nodes. 

(d)  From  a  lipoma  of  the  groin. 

(a)  An  inguinal  testis  can  be  readily  recognized  by  its  size  and  con- 
sistency. One  should  palpate  the  scrotum  as  a  matter  of  routine  in 
order  to  ascertain  whether  one  or  both  testes  have  failed  to  descend. 

(b)  From  various  sources  of  enlargement  of  the  spermatic  cord. 
An  encvsted  hvdrocele  is  tense  and  elastic  and  is  intimatelv  connected 


Fig.  249. — Conditions  to  be  Considered  in  Differential  Diagnosis  of  Hernia  and  Hydrocele. 
T,  Testis;  N,  neck  of  hernial  sacs;  IR,  internal  abdominal  ring;  ER,  external  abdominal  ring;  TV, 
tunica  vaginalis;  App,  appendix  vermiformis;  SO,  omentum  adherent  to  sac.  i.  Congenital  incomplete 
inguinal  hernia  associated  with  non-descent  of  testis.  2,  Complete  congenital  inguinal  hernia  associated  with 
non-descent  of  testis.  3,  Incomplete  acquired  inguinal  hernia  with  normal  testis.  4,  Complete  congenital 
hernia  with  normal  descent  of  testis.  5,  Direct  inguinal  hernia  with  normally  descended  testis.  6,  Acquired 
inguinal  hernia  with  normal  descent  of  testis.  7,  .Acquired  inguinal  hernia  showing  appendix  as  one  of  the  con- 
tents of  sac.     8,  Acquired  inguinal  hernia  with  adherent  omentum. 

with  the  cord.     A  lipoma  of  the  cord  is  rare.     It  feels  soft  and  doughy 
and  may  be  lobulated. 

(c)  Enlarged  and  inflamed  inguinal  lymph-nodes.  These  are  quite 
superficial  and  are  tender  to  the  touch.  There  is  often  redness  of  the 
overlying  skin  and  distinct  fluctuation  present.  In  doubtful  cases  search 
should  be  made  for  a  primary  source  of  infection  in  the  external  geni- 
talia, lower  portion  of  the  rectum  and  vagina,  and  lower  half  of  abdominal 
wall. 


INGUIXAL    HERXIA. 


413 


Fig.  250. — OxE  or  the  Steps  ix  ^L\kixg  a  Differextial  Diagxosis  betweex  an  Acquired  Hydrocele 

AND  A  Hernia. 
Grasping  the  spermatic  cord  between  the  inde.x-finger  and  thumb,  to  show  that  the  scrotal  tumor  does 
not  pass  through  the  e'cternal  abdominal  ring.     The  hydrocele  which  was  present  in  this  case  on  the  right 
side  remains  as  a  pear-shaped  swelling,  entirelj'  below  the  lingers  grasping  the  cord. 


Fig.  251. — Hernia  and  Hydrocele  in  the  Same  Patient. 
Hy,  Hydrocele  sac,  pushing  the  testis  (T)  downward  and  behind  it;  He,  left  indirect  complete  or  scrota 

hernia.     (See  text.) 


414 


THE   ABDOMEN. 


In  the  Female: 

(a)  Hydrocele  of  the  canal  of  Nuck  is  uncommon.  In  many  cases 
it  is  present  as  a  reducible  swelling  in  the  inguinal  region  for  a  long 
period,  and  then  suddenly  cannot  be  displaced.  It  may  have  the  latter 
property  of  irreducibihty  from  the  first  in  some  cases. 

It  may  be  a  unilocular  or  bilocular  sac.  At  times  it  may  become  in- 
flamed and  simulate  a  strangulated  hernia,  being  accompanied  by  severe 
pain,  tenderness,  and  vomiting. 


Fig.  252. — Inguinal  and  Femoral  Hernia  on  the  Same  Side. 
I,  Inguinal  hernia,  of  the  complete  or  scrotal  type,  which  can  be  followed  upward  to  where  it  enters  the 
internal  abdominal  ring  at  the  level  of  the  middle  of  Poupart's  ligament;  F,  femora!  hernia.     The  depression 
between  these  two  varieties  of  hernia  corresponds  to  Poupart's  ligament. 


FEMORAL  HERNIA. 
A  femoral  hernia  has  the  following  clinical  characteristics:  The 
swelling  in  the  majority  of  cases  (Fig.  252)  can  be  seen  and  felt  as  lying 
below  or  in  front  of  Poupart's  ligament  and  over  the  inner  side  of  the 
front  of  the  thigh.  The  impulse  on  coughing  and  the  neck  of  the  sac 
can  be  felt  as  lying  on  the  outer  side  of  the  pubic  spine.  The  swelhng 
is  not  so  apt  to  occur  so  easily  when  reduced,  and  after  reduction  one  can 
feel  the  pulsation  of  the  femoral  artery.     The  inguinal  canal  is  empty 


FEMORAL    HERNIA. 


415 


and  no  impulse  on  coughing  can  be  felt  after  invaginating  the  scrotum 
and  inserting  the  index-finger  into  the  external  abdominal  ring  (Fig.  242). 

In  some  cases  of  femoral  hernia  the  swelling  ascends  and  either  lies 
in  front  of  the  inner  half  of  Poupart's  hgament  or  it  passes  upward  and 
outward  toward  the  anterior  superior  spine  of  the  ihum.  In  many  of 
these  latter  two  aberrant  varieties  of  femoral  hernia,  a  differentiation 
from  an  inguinal  hernia  cannot  be  made  except  at  the  time  of  operation. 

It  was  formerly  thought  that  a  femoral  hernia  was  rare  in  men,  and 
that  an  inguinal  hernia  was  similarly  infrequent  in  the  female.  The 
foregoing  statement  has  been  proved  by  many  clinical  observations  to  be 
incorrect.     The  two  varieties  may  coexist  in  the  same  individual. 

A  femoral  hernia,  Hke  an  inguinal  hernia,  may  be  reducible  and  ir- 
reducible. It  is  more  apt  to  contain  omentum  than  the  inguinal,  and 
hence  is  more  often  irreducible.  The  following  combinations  may  exist 
(see  Fig.  253): 

1.  It  may  be  completely  reducible. 

2.  It  may  be  possible  to  reduce  the  greater  portion  of  the  tumor  and 
then  a  doughy  swelhng  remains  which  is  usually  a  subperitoneal  lipoma 
(Fig.  253)  attached  to  the  fundus  of  the  sac. 

3.  It  may  be  completely  irreducible. 

The  three  chief  conditions  from  which  a  reducible  femoral  hernia  must 
he  differentiated  are:  (i)  Incomplete  reducible  inguinal  hernia;  (2) 
psoas  abscess;  (3)  a  varicose  dilation  of  the  internal  saphenous  vein  just 
before  it  enters  the  saphenous  opening. 

The  first  three  are  given  in  the  accompanying  table : 


Reducible  Femoral 
Hernia. 

Incomplete  Redu- 
cible Inguinal 
Hernia. 

Varicosity  of 
Saphenous  Vein. 

Psoas  Abscess. 

I.  Location     of 
swelling 

Below    Poupart's    liga- 
ment. 

Above  Poupart's  liga- 
ment. 

Below  Poupart's  lig- 
ament and  along 
course  of  saphen- 
ous vein. 

Below  Poupart's, 
but  mass  also  to  be 
felt  by  deep  pal- 
pation over  Pou- 
part's ligament. 

2.  Impulse 

Distinct,  and  felt  below 
Poupart's  ligament. 

Distinct  and  felt  above 
Poupart's  ligament. 

Indistinct  and  dis- 
appears    rapidly; 
more  of  a  thrill. 

Indistinct  and  only 
when  Ijing  down. 

3.  Percussion 

Dull,  if  omentum;  tym- 
panitic,   if     intestine. 

Same  as  in  femoral. 

Dull. 

Dull. 

4.  Other  signs. . . 

Reappears   after  reduc- 
tion;    when     coughs. 
Reduction     backward 
and  upward. 

Reappears    after    re- 
duction     (outward, 
upward,  and  back- 
ward) ;      when     pa- 
tient coughs. 

Marked       enlarge- 
ment of  entire  in- 
ternal   saphenous 
vein. 

Kyphosis  and  rigid- 
ity of  spine.  Hip 
flexed. 

Occasionally  a  femoral   hernia  will   contain    the    urinary   bladder. 


4i6 


THE    ABDOMEN. 


The  diagnosis  ^  is  rarely  made  before  operation,  although  suspicion  should 
be  directed  to  this  possible  contents  when  urinary  symptoms  appear  in 
connection  with  a  femoral  hernia.  The  cystoscope  may  be  of  aid  in 
showing  the  relationship  of  the  bladder  to  the  hernia. 

An  irreducible  femoral  hernia  must  he  differentiated  from  (i)  an 
enlargement,  of  either  an  acute  or  a  chronic  nature,  of  the  lymph-nodes 
lying  over  the  saphenous  opening;  (2)  from  a  lipoma;  (3)  aneurysm  of 
the  femoral  artery. 

I.  Inflamed  or  enlarged  lymph-nodes  lie  quite  superficially.  If 
acutely  inflamed,  there  are  no  symptoms  of  disturbance  in  the  ahmen- 
tary  canal,  such  as  nausea,  vomiting,  tympanites,  etc.,  as  would  be  the 
case  in  an  inflamed  or  strangulated  femoral  hernia.  Fluctuation  is  often 
quite  distinct  and  a  primary  focus  of  infection  can  be  found  by  an  exam- 


FiG.  2S3- — Normal  and  Complicated  Femoral  Herni.e. 
PL,  Poupart's  ligament;  ER,  External  abdominal  ring;  A,  anterior  crural  nerve;  B,  femoral  arterj';  C, 
femoral  vein;  H,  hernial  sac.  i.  Most  common  form  of  femoral  hernia.  The  sac  lies  to  the  outer  side  of  the 
external  ring  and  below  Poupart's  ligament.  2,  Irreducible  form  of  femoral  hernia,  duT  to  adhesions  of 
omentum  to  interior  of  sac.  3,  A  reducible  femoral  hernial  sac  to  which  is  attached  an  irreducible  subperitoneal 
lipoma. 


ination  of  the  lower  extremity  (toes,  heel,  sole  of  foot,  leg,  knee,  etc.). 
The  enlarged  nodes  can  be  moved  upon  the  underlying  tissues,  while  in 
an  irreducible  femoral  hernia  one  can  always  feel  (except  in  very  stout 
persons)  the  neck  of  the  sac. 

2.  A  femoral  lipoma  has  no  impulse;  it  is  often  lobulated,  and  lies 
quite  superficially.  It  must  not  be  forgotten,  however,  that  a  large  hpoma 
may  be  attached  to  an  irreducible  femoral  hernial  sac.  Under  these 
circumstances  a  differentiation  is  impossible  before  operation. 

3.  An  aneurysm  shows  a  distinct  thrill,  expansile  pulsation,  and  a 
rough  systohc  bruit. 

In  inflammation  of  the  iliopsoas  bursa  there  is  pain  on  movement 
of  the  hip  and  the  swelHng  and  tenderness  lie  quite  deeply. 

^  Karewski:   "Archiv  f.  klin.  Chir.,"  Bd.  Ixxv. 


UMBILICAL    HERNIA. 


417 


UMBILICAL  HERNIA. 

There  are  three  varieties  of  this  form  of  hernia:  (a)  the  congenital, 
(b)  the  infantile,  and  (c)  the  adult. 

Congenital  Umbilical  Hernia. — This  occurs  as  the  result  of  the 
non-coalescence  of  the  two  lateral  halves  of  the  abdominal  wall.  The 
most  important  form  of  a  congenital  umbiHcal  hernia  is  that  in  which  a 
coil  of  small  intestine  or  Meckel's  diverticulum  projects  through  the 
base  or  root  of  the  umbihcal  cord.  If  the  latter  is  tied  too  close  to  the 
body,  the  knuckle  of  intestine  may  be  cut  through  and  a  septic  peritoni- 
tis result.     It  is  almost  impossible  to  recognize  this  form  unless  the  base 


Fig.  254. — Double  Femoral  Lipomata  Simulating  Femoral  Herni.s  (Eccles). 


of  the  cord  looks  broader  than  normal  and  can  be  reduced  in  size  by 
taxis,  the  enlargement  disappearing  with  a  gurgle. 

The  other  two  forms  of  congenital  umbilical  hernia  are  not  difficult 
to  recognize.  In  one  form  a  large  swelhng  is  found  in  which  the  presence 
of  viscera  can  be  seen  through  the  thin  translucent  membrane  which 
covers  it.  - 

The  umbilical  cord  is  found  at  the  summit  of  the  swelling.  The 
sweUing  usually  contains  only  coils  of  intestine,  but  other  viscera  may  be 
present.  In  the  third  form,  which  is  quite  rare,  there  is  a  complete 
eventration  and  the  prolapsed  viscera  lie  exposed  without  even  a  mem- 
branous covering. 

Infantile  Umbilical  Hernia. — These  usually  present  themselves 
in  infants,  but  may  be  found  even  in  young  adults. 
27 


41 8 


THE   ABDOMEN. 


Examination  of  the  umbilical  region  reveals  a  conical  swelling,  over 
which  there  is  a  loose  fold  of  skin.  The  protrusion  is  only  noticeable 
when  the  child  coughs  or  strains.  When  the  swelhng  is  reduced  the 
firm  edges  of  the  circular  umbihcal  ring  can  be  felt  by  inserting  the  httle 
finger. 

Umbilical  Hernia  in  Adults. — Chnically  umbihcal  hernia  in  adults 
appears  either  (a)  as  a  small  tumor  usually  lying  just  above  the  umbihcus 


^^/M 


Fig.  255. — View  of  an  Adult  Umbilical  Hernla  in  the  Earliest  Stage  of  its  DEVELopiiENT. 
This  illustration  was  made  while  the  patient  was  lying  down.     The  arrow  points  to  the  prominence  situated 
just  above  the  umbihcus  proper  (see  text).     The  photograph  was  made  while  the  patient  was  coughing,  shomng 
the  umbihcal  hernia  at  its  maximum  size. 


(Fig.  255),  or  (5)  as  a  larger  one  wliich  is  easily  recognized  and  which 
pushes  the  cutaneous  umbilicus  forward  (Fig.  256). 

Both  forms  are  more  apt  to  occur  in  stout  persons,  but  the  smaller 
variety  may  occur  even  in  lean  individuals  and  be  the  source  of  much 
discomfort.  Such  small  umbilical  herniae  may  give  rise  to  recurring 
abdominal  pain  and  various  dyspeptic  symptoms,  and,  the  hernia  being 
overlooked,  the  patient  is  often  wrongly  treated  (D.  D.  Stewart).  The 
best  method  of  examination  for  both  this  variety  of  adult  umbilical  and 
for  epigastric  herniae  is  to  inspect  and  palpate  the  median  line  of  the 


UMBILICAL   HERNIA. 


419 


abdomen  while  the  patient  coughs,  first  while  standing  up  (Fig.  256) 
and  then  upon  lying  down.  In  many  of  the  cases  the  hernia  is  assoc- 
iated with  a  properitoneal  lipoma,  as  in  the  femoral  herniae.  Under 
these  circumstances  one  sees  a  protrusion  (even  if  only  very  slight)  upon 
coughing  and  feels  an  impulse.  Upon  further  examination  it  is  found  that 
the  swelling  does  not  dis- 
appear entirely  upon  ma- 
nipulation or  upon  lying 
down,  but  that  a  soft,  often 
lobulated-mass  can  be  felt. 
The  latter  is  the  small  pro- 
peritoneal  lipoma  attached 
to  the  sac. 

These  small  umbilical 
hernia  must  be  differenti- 
ated from  fatty  tumors  of 
the  linea  alba.  This  can 
be  done  by  the  absence  of 
an  impulse  upon  coughing 
and  the  fact  that  manipu- 
lation or  posture,  such  as 
lying  down,  does  not  cause 
the  tumor  to  disappear. 

The  larger  umbihcal 
herniae  present  no  difficul- 
ties of  diagnosis.  The 
swelling  is  rounded  or 
transversely  oval  and  often 
hangs  down  toward  the 
symphysis  (Fig.  256).  The 
swelling  is  more  often  irre- 
ducible than  the  opposite. 
If  the  former  is  the  case 
the  tumor  feels  doughy 
and  lobulated  and  is  dull 

on  percussion.  The  contents  are  usually  composed  of  omentum  firmly 
adherent  to  the  sac  and  coils  of  intestine.  Incarceration  and  strancjula- 
tion  of  these  larger  umbilical  hernia  are  not  infrequent  complications. 

If  symptoms  of  intestinal  obstruction  occur  in  stout  persons  one  should 
never  fail  to  examine  the  umbihcal  region  carefully. 

The  characteristics  of  these  complications  (incarceration  and  stran- 
gulation) have  been  referred  to  on  page  403. 


Fig.  256. — Side  View  of  a  Case  of  Umbilical  Hernia. 
The  coils  of  intestine  and  omental  contents  of  this  sac  w.ere 
adherent  to  the  interior  of  the  sac,  so  that  symptoms  of  incarcera- 
tion would  appear  from  time  to  time. 


420 


THE    ABDOMEN. 


VENTRAL  HERNIA. 
These  occur  as  an  acquired  condition,  usually  in  the  linea  alba  or 
linea  semilunaris.  They  may  occur  spontaneously,  or  follow  an  oper- 
ation or  a  trauma  such  as  a  penetrating  or  crushing  wound.  I 
have  described  a  case^  of  the  traumatic  non-penetrating  variety  in 
which  a  swelling  with  unbroken  skin  appeared  within  a  short  time 
over  the  crest  of  the  ihum  in  a  patient  who  had  been  crushed  between 

two  cars.  The  abdom- 
inal muscles  and  peri- 
toneum had  been  torn 
from  the  crest  of  the 
ilium.  The  ordinary 
spontaneous  variety  of 
ventral  hernia  may  be 
found  above  or  below 
the  umbilicus.  When 
they  occur  in  the  med- 
ian hne  above  the  um- 
bilicus they  are  spoken 
of  as  epigastric  hernias. 
They  are  often  the 
cause,  like  the  small 
umbilical  hernise,  of  re- 
current abdominal  pain 
and  symptoms  of  diges- 
tive disturbance.  The 
diagnosis  of  these  epi- 
gastric as  well  as  of  the 
other  forms  of  ventral 
herniae  is  not  difficult. 
In  some  cases  there  is 
no  visible  swelling  and 
a  diagnosis  can  only  be  made  by  passing  the  fingers  along  the  median  line 
and  the  semilunar  hne  while  the  patient  coughs.  The  characteristic  im- 
pulse and  the  appearance  of  a  swelhng  enable  one  to  make  the  diagnosis. 
These  ventral  hernice  may  attain  such  a  large  size  that  practically  all 
of  the  hollow  viscera  and  omentum  are  contained  in  them.  In  very  stout 
persons  an  enormous  overhanging  mass  of  fat  will  at  first  sight  simulate 
such  a  hernia  (Fig.  243). 

In  every  case  presenting  symptoms  of  chronic  gastritis,  gallstones,. or 


Fig.  257. — Method  of  Palpating  an  Epigastric  Hernia. 
The  finger-tips   of  the  examiner  should  be  placed  successively 
upon  different  points  in  the  linea  alba  from  the  ensiform  downward 
and  the  patient  instructed  to  cough. 


'Annals  of  Surgery/'  1904. 


RARER    FORMS    OF    HERNIA.  421 

ulcer  of  the  stomach  one  should  examine  for  the  presence  of  an  epigastric 
hernia. 

A  hernia  following  a  laparotomy  can  be  recognized  from  the  history, 
the  scar,  and  the  signs  characteristic  of  all  reducible  herniae,  viz.,  a  swell- 
ing which  disappears,  often  with  a  gurgle,  upon  manipulation  or  upon 
lying  down,  and  reappears  with  an  impulse  upon  standing  up  or  after 
exertion  such  as  coughing,  etc. 


RARER  FORMS  OF  HERNIA. 
Obturator  Hernia. — This  form  can  seldom  be  recognized  until 
symptoms  of  strangulation  appear.  The  protrusion  occurs  through  the 
obturator  foramen  and  can  occasionally  be  felt  externally  just  below  the 
pubes  on  the  inner  side  of  the  femoral  vessels.  It  may  also  cause  pain, 
which  is  referred  to  the  knee  along  the  distribution  of  the  obturator  nerve. 
If  strangulation  occurs,  the  condition  must  be  differentiated  from  rheuma- 
tism by  the  absence  in  the  latter,  of  symptoms  of  intestinal  obstruction, 
and  from  pelvic  peritonitis,  by  the  bimanual  examination  of  the  pelvis. 
Obturator  herniae  are  most  apt  to  occur  in  elderly  females. 

Diaphragmatic  Hernia. — This  has  been  previously  described  in 
connection  with  injuries  of  the  thorax  (page  197). 

Lumbar  Hernia. — This  may  occur  anywhere  behind  the  linea 
semilunaris  and  between  the  last  rib  and  crest  of  the  ilium.  These 
herniae  may  be  congenital  or  acquired,  the  former  often  being  bilateral. 
The  acquired  form  may  be  either  spontaneous  or  traumatic.  The  former 
usually  protrude  through  the  triangle  of  Petit,  just  below  the  twelfth  rib, 
as  a  swelling  which  has  all  the  signs  just  referred  to  as  typical  of  a  re- 
ducible hernia.  One  must  differentiate  the  spontaneous  variety  from  a 
lipoma,  and  from  a  cold  abscess  due  to  disease  of  the  spine. 

The  traumatic  variety  may  either  follow  an  operation  upon  the  kidney 
or  some  crushing  injury,  such  as  described  under  traumatic  ventral 
hernia. 

The  diagnosis  does  not  differ  from  that  of  the  spontaneous  variety. 

Sciatic  Hernia. — This  occurs  through  the  sacrosciatic  foramen, 
forming  a  swelling  in  the  gluteal  region.  Very  few  cases  have  been 
recorded  of  this  variety  of  hernia.  When  the  hernia  is  small  it  may 
escape  recognition  unless  a  careful  examination  for  such  symptoms  as 
pain  over  the  gluteal  region  be  made.  If  the  hernia  is  large  it  gives  rise 
to  a  distinct  gluteal  swelhng  with  a  marked  impulse  on  coughing  and  re- 
ducibihty  with  a  gurgling  sound  if  intestine  is  present  in  it.  It  must  be 
differentiated  frorn  an  abscess  due  to  hip  disease,  from  a  hpoma,  and 
from  an  aneurysm. 


CHAPTER  V. 

THE  EXTREMITIES. 

Injuries  of  the  Soft  Tissues,  Bones,  and  Joints. 

In  attempting  to  make  a  diagnosis  as  to  the  nature  of  injuries  received 
as  the  result,  either  of  a  recent  accident,  or  of  one  sustained  at  some 
previous  period,  the  following  possibihties  must  be  borne  in  mind,  and 
each  one  ehminated  by  a  process  of  exclusion,  based  upon  a  thorough 
examination  and  history  of  the  case. 

These  possible  injuries  and  their  complications  are: 

INJURIES  OF  THE  SOFT  PARTS. 
Location.  Nature.  Possible  Coiiplicatioxs  or  Re- 

sults. 

1.  Skin  and  subcu- 

taneous tissue,  .(a)  Penetrating  wounds;    lacer-       (a)  Infection  with   ordinary  pyo- 
ated,     punctured,     incised,  genie  organisms  (streptococci 

gunshot.  and  staphylococci). 

(b)   Non-penetrating  wounds  or       (b)   Tetanus, 
contusions. 

(c)  Erysipelas  and  erysipeloid. 

(d)  Infection   with    gas-producing 
bacUli. 

(e)  Anthrax. 

2.  ISIuscles Contusions,  penetrating  wounds,       Traumatic   myositis,   myositis  os- 

rupture  of  muscles.  si&cans.     Loss  of  function. 

3.  Tendons  and  ten- 

don-sheaths..-Lacerated    or    incised    wounds.  Infective    tenosynovitis,    ganglion. 
Rupture   of   tendon,    dislo-  Loss  of  function, 

cation  of  tendons. 

4.  Bursae Contusions.   Penetrating  wounds.  Acute  suppurative  and  non-suppu- 

rative  bursitis. 

5.  Blood-vessels Penetrating  wounds    or    contu-       Phlebitis.     Gangrene    of   extremi- 

sions  of  arteries  or  veins.  ties.    Ulcers  (trophic).    Trau- 

matic aneurysms. 

6.  Nerves Contusions  or  penetrating  wounds     Neuritis.     Paralysis  of  motion    or 

of  nerve-trunks  or  filaments.  sensation  or  both. 

INJURIES  OF  THE  BONES  AND  JOINTS. 
Location.  Nature.  Complications. 

1.  Bones Contusions        or    '    penetrating       Periostitis  or  necrosis  of  bone. 

wounds       of       periosteum.       Infection.    Injur}' of  nerve.    Injury 
Simple    or  compound  frac-  of  vessels.     (Gangrene  or  an- 

tures.  eurysm.)     Coxa  vara  trauma- 

tica. 

2.  Joints Sprains.     Penetrating     wounds.       Septic  arthritis.     Injury  to  carti- 

Dislocations:     simple     and  lages  or  ligaments.     Paralysis 

compound.  of  nerves. 

422 


INJURIES    OF    THE    SOFT   PARTS.  423 


INJURIES  OF  THE  SOFT  PARTS. 
The  most  important  points  to  be  determined  in  the  examination 
of  an  injury  of  the  extremities  are:  (a)  the  location  of  the  injury;  (b) 
its  nature  or  extent;  (c)  whether  complications  exist  or  not.  In  order 
to  be  able  to  answer  these,  a  careful  history  must  be  taken  of  the  man- 
ner in  which  the  accident  occurs,  next  the  physical  examination  of  the 
part  involved,  as  well  as  the  observation  of  the  general  condition. 

Injuries  of  the  skin  consist  of  either  simple  or  complicated  wounds. 
In  the  simple  variety  there  is  an  injury  of  the  skin  and  subcutaneous 
tissues  alone,  either  {a)  in  the  shape  of  a  lacerated,  incised,  punctured, 
or  gunshot  wound,  often  called  a  penetrating  wound,  or  (b)  a  collec- 
tion of  blood  in  the  subcutaneous  connective  tissue  of  greater  or  less 
extent,  called  a  non-penetrating  wound  or  contusion  (bruise). 

In  the  penetrating  wounds  of  the  simple  variety,  there  is  no  difficulty  in 
making  a  diagnosis.  The  edges  of  the  wound  gape  to  a  variable  extent 
and  the  subcutaneous  fat  may  prolapse.  The  amount  of  bleeding 
varies  according  to  the  vessels  severed.  If  from  an  artery,  it  occurs 
intermittently  and  is  bright  red  in  color.  If  from  a  vein,  the  flow  is 
continuous  and  of  a  darker  color.  If  from  the  capillaries,  called  par- 
enchymatous hemorrhage,  it  is  steady  in  character,  but  the  amount 
is  not  so  great  as  is  that  from  an  artery  or  vein. 

All  the  penetrating  wounds  of  the  skin  may  be  associated  with 
more  or  less  contusion,  i.  e.,  laceration  of  the  soft  parts  with  hemorrhage 
into  them,  or  the  latter  condition,  known  as  a  contusion,  may  exist 
without  any  such  penetrating  wound. 

A  simple  contusion  causes  a  painful  sweUing  of  the  skin  which  may 
either  be  quite  circumscribed  or  occupy  a  considerable  area.  Dis- 
coloration of  the  skin  often  occurs  at  a  very  early  period,  or  may  not 
appear  until  after  some  days,  the  skin  becoming  at  first  bluish,  then 
yellowish  in  color. 

Both  penetrating  and  non-penetrating  wounds  of  the  skin  may 
be  compHcated  in  the  following  ways :  {a)  There  may  be  an  associated 
injury  of  the  other  structures  in  the  hmb.  (6)  The  injury  may  be 
complicated  by  symptoms  of  shock  or  of  general  anemia  from  hemor- 
rhage, (c)  One  of  the  so-called  accidental  wound  infections  or  other 
sequelae  may  be  complicating  the  chnical  picture. 

Signs  of  Injury  of  Other  Soft  Parts. — These  may  often  be  ascer- 
tained by  inspection  of  the  wound.  In  some  it  will  be  necessary 
either  to  retract  the  edges  or  to  secure  the  information  through 
{a)  the  discovery  of  loss  of  function  of  a  muscle,   tendon,   or   nerve; 


424 


THE    EXTREMITIES. 


(b)    through   hemorrhage   or   gangrene    resulting   from   injury    of   an 
artery  or  vein. 

If  it  becomes  necessary  to  examine  a  wound  the  utmost  precaution 
should  be  taken  to  prevent  infection.  In  the  majority  of  cases  the  loca- 
tion of  the  wound  in  relation  to  important  anatomic  structures  and  the 
obsen^ation  of  loss  of  function  will  suffice,  so  that  a  direct  inspection 
of  the  wound  is  rarely  necessary  for  diagnostic  purposes. 


Fig.  258. — AIethod  of  Measuring  the  Forearm  ix  Order  to  Determine  Atrophy  of  the  Same. 

The  patient  may  be  examined  while  lying  down.     The  point  for  measuring  the  circumference  is  at  the  level 

of  the  greatest  amount  of  muscular  development  of  the  forearm. 


INJURIES  OF  MUSCLES.  TENDONS,  AND  TENDON-SHEATHS. 
Contusions  of  Muscles. — A  contusion  of  a  muscle  may  be  sus- 
pected if  there  is  inability  to  use  the  muscle  combined  with  locahzed 
tenderness  and  pain  shortly  after  the  injury.  A  little  later,  such  muscular 
injury  can  be  suspected  if  there  is  rapid  atrophy,  as  determined  either 
by  palpation  or  by  the  measurement  of  the  circumference  of  the  hmb 


INJURIES    OF    MUSCLES,    TENDONS,    AND    TENDON-SHEATHS. 


42; 


and  comparing  it  with  that  of  the  opposite  one  (Fig.  258).  Such  loss  of 
function  and  atrophy  of  a  muscle  may  be  due  to  injury  of  the  nerves 
supplying  it  or  to  non-use  of  the  Hmb  following  bone  or  joint  injuries. 
The  latter  are  far  more  frequently  followed  by  atrophy  than  is  an 
ordinary  contusion  of  a  muscle. 


Fig.  25Q.— Method  of  Measuring  the  Circumference  of  the  Arm  Region  Proper,  in  Okuer  to  Deter- 
mine Atrophy  of  Muscles. 
This  may  be  performed  either  with  the  patient  sitting  up  or  lying  down.  In  all  of  these  measurements  of 
the  circumference  of  extremities  one  of  the  most  accurate  methods  is  to  employ  a  steel  tape-measure,  and  to 
take  as  the  beginning-point  some  inch  or  centimeter  measurement  which  is  not  too  near  the  end  of  the  tape, 
and  to  hold  this  point  opposite  some  point  to  which  the  circumference  of  the  arm  may  cause  llic  c.xammer  to 
stretch  the  tape-measure.  The  second  point  is  noted,  and  the  distance  of  the  beginning  of  the  tape-measure 
to  the  starting-point  subtracted  from  it.  For  example,  if  the  starting-poinl  chosen  was  the  mark  at  the  end 
of  the  one-inch  measure,  and  the  second  point  after  the  circumference  had  been  measured  was  eight  mches,  the 
circumference  of  the  arm  would  be  the  difference,  or  seven  inches. 


Another  sequel  of  a  muscular  contusion  is  the  formation  of  bone 
in  it,  a  condition  known  as  Iraiimatic  ossijyiug  myosilis  (myositis  ossi- 
ficans traumatica).  This  condition  of  ossification  between  or  within 
the  muscles  may  follow  cither  repeated  slight  traumas  or  a  single  but 
severe  one. 


426 


THE    EXTREMITIES. 


The  former  are  usually  associated  T\'ith  certain  occupations  in  which 
the  muscles  are  subject  to  frequent  injur}^,  as  the  rider's  bone  in  the 
adductor  lon2;u3  muscle  of  cavaln'  riders. 

In  both  varieties  of  cases  there  is  to  be  felt  in  the  muscles  a  hard 
bony  mass  whose  formation  can  be  directly  traced  to  the  trauma.  The 
presence  of  the  osseous  deposit  can  be  confirmed  by  an  .v-ray  exami- 
nation. 

Ruptures  of  Muscles  and  Tendons. — These  may  occur  in  any 

of  the  muscles  or  tendons  of  the  ex- 
tremities, but  are  more  frequent  in  cer- 
tain ones.  Pure  muscular  ruptures  occur 
oftenest  in  the  biceps  of  the  arm  and  in 
the  quadriceps  extensor  of  the  thigh. 
Rupture  of  tendons  occurs  most  fre- 
quently in  the  quadriceps  extensor  ten- 
don, either  above  or  belovv-  the  patella. 
The  tendo  AcliilHs  and  the  biceps  bra- 
chii,  either  at  its  upper  or  lower  ends, 
are  next  in  frequency.  These  ruptures 
seldom  occur  as  the  result  of  external 
violence,  but  almost  always  from  a 
violent  contraction  during  unusual  ex- 
ertions. 

These  ruptures  of  muscles  or  ten- 
dons may  be  recognized  from  a  sudden 
severe  pain  in  the  affected  muscle  or 
tendon,  inabihty  to  use  it,  and  the  pal- 
pation of  a  gap  at  the  point  of  rup- 
ture. 

In  the  case  of  muscular  ruptures  this 
gap  or  depression  is  marked  on  either 
side  by  a  prominence  formed  by  the  torn 
ends  of  the  maiscle.     This  gap  is  soon 
filled  with  a  clot  and  becomes  less  prominent. 

In  tendon  rupture,  especially  of  the  lower  end  of  the  biceps,  hga- 
mentum  patellae,  or  of  the  tendo  Achillis  the  gap  is  ver>'  distinct  and 
can  be  readily  feh  owing  to  the  superficial  positions  of  these 
tendons. 

Tendons  may  be  pulled  away  from  their  points  of  origin  or  attach- 
ment by  violence  such  as  occurs  when  a  hand  or  foot  or  the  entire  ex- 
tremitv  is  torn  oft"  from  the  remainder  of  the  body.     The  tendo  Achillis 


Fig.  260. — Flexion  Contracture  of  All 

OF  THE  Fingers  of  the  Hand. 

Caused  by  a  crushing  Lajury  which  opened 

up  the  flexor  tendon-sheaths. 


INJURIES    OF   MUSCLES,    TENDONS,    AND    TENDON-SHEATHS.         427 

and  ligamentum  patellae  are  often  torn  from  their  respective  attach- 
ments, by  sudden  and  violent  muscular  movements. 

Dislocations  of  Tendons. — The  only  tendons  which  have  so  far 
been  described  as  subject  to  this  injury  are  those  of  the  peroneal  mus- 
cles and  long  head  of  the  biceps.  The  condition  can  be  recognized 
clinically  if  during  contraction  of  the  tendon  the  latter  is  felt  as  if 
springing  out  of  its  normal  location. 


Fig.  261. — Direct  Posterior  View  of  a  Case  of        Fig.  262. — Lateral  View  of  Case  of  Olecranon 
Olecranon  Bursitis.  Bursitis. 

Note  the  swelling  over  the  olecranon  process.  The  white  arrow  points  to  the  prominent  olecranon 

bursa. 


Hernias  of  Muscles. — Either  following  severe  contusions  of  the 
muscles  with  tears  of  the  fasciae  or  after  penetrating  wounds  of  the 
latter,  a  localized  swelling  appears  during  contraction  and  vanishes 
during  relaxation  of  the  muscle.  After  disappearance  of  the  swelling 
a  distinct  gap  can  be  felt  in  the  fascia  through  which  the  muscular 
hernia  occurred.  This  injury  is  most  apt  to  take  place  in  the  mus- 
cles of  the  thigh  and  leg  and  can  be  readily  recognized. 


428  THE    EXTREMITIES. 

Penetrating  Wounds  of  Muscles,  Tendons,  and  Tendon- 
sheaths. — Penetrating  wounds  of  muscles  often  occur  as  a  part  of 
complicated  wounds  of  the  skin,  and  can  be  readily  recognized  upon 
inspection  of  tlie  cut  edges  or  through  loss  of  function  of  the  muscles. 
If  the  wounds  become  infected,  a  purulent  myositis  may  follow  with 
sloughing  of  some  of  the  muscle  fibers.  Tendon  injuries  occur  oftenest 
on  the  anterior  or  posterior  surfaces  of  the  wrist  or  around  the  ankle 
and  foot.  The  diagnosis  may  be  made,  either  from  inspection  of  the 
wound  and  observing  the  presence  of  the  cut  ends  or  by  testing  for 
loss  of  function  in  the  corresponding  parts,  e.  g.,  inability  to  flex  or 
extend  the  fingers  or  toes. 

A  partial  severing  of  a  tendon  is  of  no  significance  unless  the  wound 


Fig.  263. — Bursitis  of  Metacarpo-phalangeal  Bursa. 
B,  Points  to  prominence  due  to  bursa. 

is  quite  deep.  Wounds  of  the  hand  in  which  the  tendon-sheaths  have 
been  opened  with  or  without  laceration  of  the  tendons  are  of  great 
importance  for  two  reasons:  (a)  the  possibihty  of  infection  spreading 
to  the  forearm;  (b)  the  fact  that  the  wound  in  the  tendon-sheath  is 
very  prone  to  adhere  to  the  skin  wound,  causing  serious  cicatricial  defor- 
mities (Fig.  260). 

Injuries  of  the  Bursae. — These  may  occur  either  in  the  form  of 
contusions  or  of  penetrating  wounds.  In  contusions  of  the  bursae 
there  is  rapid  swelhng,  local  tenderness,  and  pain.  Suppuration  may 
take  place  without  any  communication  with  the  overlying  skin  being 
present. 

Before  infection  has  occurred,  the  diagnosis  may  be  made  by  not- 
ing the  presence  of  a  painful  swelling,  which  usually  fluctuates  dis- 


INJURIES    OF    BLOOD-VESSELS. 


42Q 


tinctly,  situated  at  the  locations  of  the  more  superficial ]^bursae,  viz., 
the  olecranon  (Fig.  261),  metacarpophalangeal  (Fig.  263),  prepatel- 
lar, less  often  the  subdeltoid,  ischiadic,  tendo  Achillis,  and  trochan- 
teric bursce. 

Not  infrequently   the   skin   around   the   swelling   shows   evidences 
of     extensive     contu-  ^ 

sion. 

If  infection  occurs 
after  a  contusion  or  a 
penetrating  wound  of 
a  bursa,  the  swelhng 
becomes  very  tender, 
there  is  local  redness, 
heat,  and  infiltration 
of  the  overlying  skin, 
as  well  as  the  general 
signs  of  infection,  such 
as  elevation  of  temper- 
ature and  pulse-rate, 
leukocytosis,  etc. 

A  knowledge  of 
the  location  of  the 
more  common  bursae 
is  of  great  importance 
clinically  (Fig.  265). 

Injuries  of  the 
deeper  bursae,  such  as 
the     subdeltoid,    ilio- 


FiG.  264. — Dorsal  View  of  Case  shown  in  Fig.  263.  (Lateral 
View),  of  Bursitis  of  the  Metacarpo-phalangeal  Bursa  of 
Index-finger. 


psoas,  or  semimem- 
branous', may,  if  they 
suppurate,  play  a  role 

in  spreading   the  infection  to  the   large  joints  with  which  they  often 
communicate. 


INJURIES  OF  BLOOD-VESSELS. 
Injuries  of  Arteries. — These  may  occur  in  any  of  the  arlrrics 
of  the  upper  and  lower  extremities  as  llie  result  (a)  of  pendraling 
wounds  with  sharp  instruments,  such  as  a  knife,  razor,  bayonet,  etc. 
(b)  In  severe  contusions  of  a  limb,  when  an  artery  like  the  femoral 
or  brachial  is  firmly  compressed  against  the  pubes  or  humerus  respec- 


43  o 


THE    EXTREMITIES. 


tively.  (c)  As  a  complication  of  gunshot  wounds  or  explosion  of 
shells,  etc.  (d)  In  extensive  crushing  injuries  of  a  hmb.  (e)  As 
the  result  of  a  simple  or  compound  fracture,  a  fragment  either  pene- 
trating  the   vessel   or   the  wall   becoming   necrotic   from   pressure  of 

the   displaced  fragments  upon 
it  (Fig.  266). 

The  diagnosis  of  an  arterial 
injur}'  is  based  upon  (a)  certain 
primary  symptoms  which  im- 
mediately follow  the  injur}^;  (b) 
other  signs  appearing  at  a  later 
period,  so-called  secondary 
signs.  The  symptoms  indicat- 
ing an  arterial  injur}^  which 
occur  immediately  depend  upon 
Avhether  the  vessel  has  been 
completely  or  partially  severed 
and  whether  the  hemorrhage  has 
ceased  spontaneously. 

If  one  can  observe  the  char- 
acteristic red  spurting  of  an  ar- 
terial hemorrhage,  the  diagnosis 
is  easy.  The  cases  are  rarely 
seen  at  such  a  time,  the  bleed- 
ing, if  it  has  been  severe,  either 
having  caused  speedy  death  or 
the  extreme  anemia  occasioned 
by  great  loss  of  blood  results  in 
such  slowing  of  the  heart's  ac- 
tion, that  only  a  shght  flow  takes 
place  from  the  end  of  the  torn 
artery. 

The  majority  of  cases  are 
seen  at  a  time  when  the  hemor- 
rhage has  been  temporarily 
checked,  either  through  the 
feeble  action  of  the  heart  fol- 
lowing the  severe  loss  of  blood  or  as  a  result  of  a  plugging  of  the  tear 
in  the  artery  by  a  thrombus  or  retraction  of  the  vessel. 

If  a  large  wound  exists  in  which  the  torn  vessel  can  be  seen,  the 
diagnosis  is  also  easilv  made. 


Fig.  265. — Location  of  Various  Burs-e. 

I,  Subdeltoid;  2,  olecranon;  3,  trochanteric;  4,  isch- 
ial; 5,  bursa  beneath  tendo  AchilUs  at  its  insertion  in 
the  OS  calcis. 


INJURIES    OF    BOOOD-VESSELS. 


431 


Usually  a  diagnosis  depends  upon  the  recognition  of  other  pri- 
mary and  secondary  signs.  The  remaining  primary  signs  are:  (a) 
the  absence  of  a  pulse  in  the  peripheral  vessels  of  the  cold  and  pale 
limb;  (&)  the  presence  of  a  rough  rasping  murmur,  synchronous  with 
the  pulse  and  resulting  from  the  projection  of  a  thrombus  into  the 
lumen;  (c)  the  appearance  of  a  large  hematoma  in  the  neighborhood 
of  the  injured  vessel  accompanied  by  signs  of  severe  anemia. 

The  so-called  secondary  or  late  evidences  of  an  arterial  injury  are 
the  appearance  (a)  of  a  traumatic  or  false  aneurysm;  (&)  of  beginning 
gangrene  of  the  limb;  (c)  the  occurrence  of  severe  secondary  hemor- 
rhage, usually  about  the  sixth  to  ninth  day. 

Traumatic  or  jalse  aneurysms  are  more  apt  to  follow  stab  than  gun- 


FiG.  266. — -Sdpracondyloid  Fracture  of  Femur. 
The  illustration  shows  how  the  gastrocnemius  muscle,  whose  action  is  represented  by  the  black  arrow,  ter- 
minating at  the  letter  G,  causes  the  lower  fragment  to  be  pulled  downward  and  backward,  impinging  upon  the 
pophteal  artery  and  vein,  and  resulting  in  gangrene  of  the  leg  in  some  instances. 

shot  wounds.  Clinically  they  can  be  recognized  by  the  appearance 
of  a  swelling  in  the  vicinity  of  the  original  wound  or  proximal  to  it 
(Fig.  267),  which  shows  a  distinct  expansile  thrill  and  a  blowing,  often 
rough,  systolic  murmur.  At  a  later  period,  varicosities  of  the  super- 
ficial veins  become  very  marked.  If  both  artery  and  vein  are  injured 
simultaneously,  and  this  is  not -infrequent,  the  symptoms  in  the  early 
period  do  not  differ,  as  a  rule,  from  those  of  injury  of  the  artery  alone, 
except  by  an  increased  amount  of  edema  of  the  limb.  Later  on,  this 
swelling  becomes  quite  marked  and  is  accompanied  by  other  signs, 
such  as  a  continuous  murmur,  which  is  transmitted  in  a  proximal  and 
distal  direction  in  both  artery  and  vein.  There  is  frequently  also 
distinct  venous  pulsation  and  the  veins  become  varicose  (Fig.  199). 
The  arteries  most  often  injured  are  the  subclavian,  axillary,  bra- 


432 


THE   EXTREMITIES. 


chial,  and  radial  in  the  upper,  and  tlie  femoral  and  popliteal  in  the  lower 
extremity. 

Injuries  of  the  Veins. — With  the  exception  of  injuries  of  the 
larger  venous  trunks,  these  are  of  less  importance  and  are  rarer  than 
the  same  conditions  in  the  arteries.  As  in  the  case  of  the  latter,  the 
diagnosis  may  be  made  from  certain  primary  or  immediate  and  secon- 
dary or  late  signs.  They  may  occur  as  the  result  of  the  same  causes 
which  were  mentioned  as  producing  arterial  injury.     In  addition,  the 

veins  are  often  wounded 
during  operations  for  the 
removal  of  tumors  or  en- 
larged lymph-nodes,  and 
rarely  during  the  perform- 
ance of  a  herniotomy.  The 
larger  trunks  most  often  in- 
jured are  the  subclavian, 
axillary,  brachial,  femoral, 
and  pophteal.  The  primary 
signs  of  vein  injury  are: 
(a)  Hemorrhage,  Avhich  is 
seldom  as  great  as  after  in- 
jury of  the  corresponding 
artery,  but  may  be  quite 
severe;  it  increases  when 
the  limb  is  held  do vtl  .  The 
blood  is  of  a  dark  color  and 
flows  in  a  steady  stream. 
{h)  The  entrance  of  air  in- 
to the  vessels.  This  rarely 
occurs  in  wounds  of  the 
veins  of  the  extremities. 

The  late  or  secondary 
signs  are  (a)  the  formation 
of  an  arteriovenous  or  {b)  of  a  varicose  aneurysm,  if  the  artery  is  simul- 
taneously injured  (page  433).  These  are  usually  the  resuh  of  stab  and 
gunshot  wounds  and  only  occur  in  the  larger  vessels  of  the  extremities. 
The  symptoms  of  arteriovenous  aneurysms  vary  somewhat  accord- 
ing to  the  relations  of  the  two  vessels. 

I.  If  there  is  a  wide  communication  of  an  arterial  aneurysm  with 
the  vein,  the  pulse  is  transmitted  to  the  latter,  gradually  decreasing 
in  intensity  from  the  point  of  contact  in  both  directions.     In  addition 


Fig.  267. — Anterior  View  of  Patient  with  Traumatic 
Aneurysm  of  Femoral  Artery  and  Secondary  Aneur- 
ysm OF  External  Iliac  Artery. 

(i)  The  black  semicircle  below  this  figure  indicates  the  size 
of  the  iliac  aneurysmal  sac  as  palpated  through  the  abdom- 
inal wall;  (2)  extent  of  sac  of  aneurysm  in  femoral  artery;  (3) 
wound  of  entrance  of  knife. 


INJURIES    OF   THE   NERVES.  433 

to  the  systolic  arterial,  there  is  a  continuous  rough,  sawing,  venous 
murmur,  often  more  marked  during  the  diastole. 

2.  In  an  aneurysmal  varix  compression  of  the  artery  above  the 
communication  causes  the  sac  to  disappear,  which  is  not  the  case  in 
the  first  named  variety.  There  is  considerable  edema  of  the  limb  and 
marked  varicosities. 

3.  If  there  is  a  direct  narrow  communication,  between  the  artery 
and  vein,  the  only  sign  is  a  continuous  rasping  murmur  transmitted 
along  the  vein,  which  ceases  when  the  artery  is  compressed. 

Before  leaving  the  diagnosis  of  vessel  injury,  it  is  desirable  to  refer 
briefly  to  the  fact  that  apparently  insignificant  wounds,  wherever  sit- 
uated, in  the  body  of  a  class  of  persons  suffering  from  a  condition 
knowTi  as  hemophilia,  may  bleed  profusely  and  most  persistently.  This 
complication  must  always  be  borne  in  mind  in  cases  of  obstinate  hem- 
orrhage from  comparatively  insignificant  wounds. 

In  addition  to  such  unusual  hemorrhage  from  wounds,  whether 
operative  or  accidental,  these  individuals  often  have  other  symptoms 
of  diagnostic  value. 

These  latter  are:  {a)  The  occurrence  of  purpuric  spots,  petechise,  or 
ecchymoses  into,  or  of  hematomata  beneath  the  skin,  {h)  Hemorrhages 
from  various  mucous  cavities,  Hke  the  stomach  or  intestine,  (c)  The 
occurrence  of  multiple  joint  swelling  as  described  on  page  624. 


INJURIES  OF  THE  NERVES. 

These  may  be  partial  or  complete.  The  former  are  called  con- 
tusions and  the  latter  lacerations  or  solution  of  continuity.  The  nerves 
of  the  extremities  belong  to  the  class  of  mixed  motor  and  sensory  nerves, 
hence  any  injury  will  cause  a  disturbance  of  their  function  which  varies 
according  to  the  degree  of  the  injury. 

The  diagnosis  may,  in  general,  be  made  from  the  following  specific 
signs : 

1.  Paresis  or  paralysis  of  the  muscles  supplied  by  the  injured  nerve 
or  nerves.  The  paresis  or  paralysis  will  be  either  complete  or  incom- 
plete, depending  upon  whether  the  affected  muscle  or  muscles  are  sup- 
plied by  the  injured  nerve  alone  or  by  several  nerves. 

2.  Disturbances  of  sensation.  There  may  be  simple  paresthesia 
or  complete  anesthesia.  If  the  latter  exists,  the  area  will  seldom  cor- 
respond exactly  to  the  normal  cutaneous  area  supplied  by  the  nerve. 
This  is  due  to  the  fact  that  the  anastomosis  of  the  nerves  of  the  skin 
is  so  free  that,  within  a  short  period,  the  neighboring  filaments  often 

28 


434  THE    EXTREMITIES. 

assume  the  function  of  the  sensory  endings  of  the  injured  nerve.  Com- 
plete anesthesia  usually  follows  the  injury  of  several  nerves  of  an  ex- 
tremity. 

In  addition  to  the  disturbances  of  tactile  sense,  there  is  often  severe 
pain  along  the  course  of  the  nerve.  This  is  most  frequently  the  case 
in  those  nerves  which  are  gradually  compressed,  as  by  a  callus  or  by 
the  end  of  a  dislocated  bone.  The  appearance  of  pain  usually  indi- 
cates an  incomplete  solution  of  continuity.  It  has  been  frequently 
shown  that  compression  of  mixed  sensory  and  motor  nerves  first  causes 
disturbances  of  the  tactile  sense  and  ability  to  recognize  cold,  while 
at  a  later  period  there  is  absence  of  heat  sensation  and  the  appearance 
of  pain. 

3.  Vasomotor  and  trophic  changes.  The  former  causes  redness 
and  local  rise  in  temperature,  which  are  followed  gradually  by  cyano- 
sis and  coldness  of  the  limb.  The  trophic  changes  are  usually  most 
marked  in  the  skin,  rarely  in  the  bones  and  joints  unless  the  injury 
occurs  early  in  life.  The  skin  becomes  smooth  and  shining,  loses  its 
elasticity,  and  deep  ulcerations  may  occur.  There  is  marked  atrophy 
of  the  muscles  and  the  joints  become  stiff  and  painful. 

4.  Changes  in  electrical  reaction.  In  mild  forms  of  contusion  due 
to  compression  of  the  nerve  there  is  seldom  any  change.  Even  though 
the  paralysis  be  a  complete  one,  after  a  contusion  there  may  be  no 
change  in  the  electrical  reaction. 

If,  however,  the  nerve  is  completely  severed,  the  response  of  the 
nerve  toward  both  faradic  and  galvanic  stimulation  begins  to  sink 
about  the  second  day,  and  ceases  completely  by  the  end  of  the  second 
week.  The  affected  muscles  also  fail  to  respond  to  the  faradic  cur- 
rent, but  show  an  increased  irritability  toward  the  galvanic.  These 
changes  may  persist  for  some  time  after  the  muscles  begin  to  respond 
to  voluntary  impulses. 

5.  The  appearance  of  a  tumor  at  the  seat  of  injury.  In  some  cases 
neuromata  develop  at  the  point  where  the  nerve  has  been  either  con- 
tused or  severed.  A  spindle-shaped  enlargement  can  often  be  felt 
at  the  point  where  the  nerve  has  been  injured  or  cut,  after  a  variable 
period,  usually  two  to  three  months.  In  some  cases,  as  in  amputa- 
tion stumps,  it  may  be  excjuisitely  tender  to  the  touch. 

Injuries  of  the  nerves  occur  as  the  result  either  of  pressure  or  of 
laceration  of  the  nerve.  The  former  may  (a)  immediately  follow  a  single 
trauma,  like  a  blow  or  a  kick  or  the  apphcatibn  of  a  constrictor;  (b) 
it  may  follow  the  pressure  of  crutches  (crutch  paralysis) ;  (c)  the  nerve 
may   become   compressed   between  the   fragments   of  a  fracture  or  by 


INJURIES    OF    THE    INDIVIDUAL    NERVES. 


435 


a  callus  (Fig.  268).  Lacerations  of  nerves  follow  (a)  gunshot,  stab, 
or  any  variety  of  wound  made  by  cutting  or  tearing  violence;  (b) 
penetration  by  a  fragment  of  bone  in  fractures;  (c)  crushing  of  the 
nerve  without  an  external  wound. 


INJURIES  OF  THE  INDIVIDUAL  NERVES. 

The  circumflex  nerve  is  most  frequently  injured  in  connection 
with  fracture  of  the  surgical  neck  of  the  humerus.  It  may  also  be  injured 
in  dislocations  of  the  shoulder 
as  well  as  in  severe  sprains, 
without  fracture.  The  prin- 
cipal symptom  is  paralysis  of 
the  deltoid  resulting  in  inabil- 
ity to  raise  the  arm  from  the 
chest  and  in  such  marked  atro- 
phy that  the  normal  con\'ex 
outline  of  the  shoulder  is 
lost. 

The  musculospiral  nerve 
is  more  often  injured  than  any 
other  in  the  body.  In  the  ax- 
illa it  may  be  compressed  by 
the  head  in  dislocations  of  the 
humerus  or  by  the  pressure  of 
a  crutch.  At  the  middle  of 
the  shaft  (Fig.  268)  it  may  be 
compressed  by  too  tight  an  ap- 
plication of  a  constrictor,  or 
more  often  by  being  caught  in 
a  callus  in  fractures  at  this 
level.  It  may  be  torn  by 
blows  over  this  place  without 
any  wound  of  the  skin.  Its' 
continuation,  the  radial  nerve, 
is  often  severed  in  gunshot 
wounds  of  the  forearm  or  in  incised  wounds  just  above  the  wrist. 

The  motor  symptoms  vary  somewhat  according  to  the  level  of  the 
injury:  (a)  If  in  the  axilla,  the  elbow,  wrist,  and  fingers  cannot  be 
extended,  (b)  If  at  the  middle  of  the  humerus,  the  elbow  can  be  ex- 
tended but  there  is  inabihty  to  supinate  the  forearm  and  to  ilex  it,  when 


Fig.  268. — Musculospiral  Nerve  Compressed  ^y  a 
Callus  Resulting  prom  a  Fracture  in  Middle  of 
Shaft  of  Humerus  (Lejars). 

MS,  Musculospiral  nerve  above  and  below  point  of  com- 
pression by  callus. 


436  THE    EXTREMITIES. 

half-way  between  supination  and  pronation  (supinator  longus  action). 
There  is,  in  addition,  the  loss  of  movements  of  extension  of  the  fin- 
gers and  wrist,     (c)  If  below  the  humerus,  the  elbow  can  be  extended 


Fig.  269. — Wrist-drop. 
Due  to  pressure   paralysis  of  the  musculospiral  nerve,  following  too   tight  an  appUcation  of   an  Esmarch 


^:?*'- 


FiG.  270. — Claw-hand  (Main  en  griffe)  Following  Ulnar  Paralysis  (Leube). 


and  forearm  supinated,  but  the  inabihty  to  extend  the  wrist  and  fin- 
gers is  more  prominent  (Fig.  269),  causing  the  deformity  known  as 
wrist-drop. 

The  sensory  symptoms  are  often  so  shght  as  to  escape  nodce  at 


INJURIES    OF   THE    INDIVIDUAL    NERVES. 


437 


first,  because  the  median  and  ulnar  nerves  establish  a  collateral  supply. 
When  anesthesia  is  present  it  is  most  marked  over  the  back  of  the 
thumb  and  index- finger. 

The  ulnar  nerve  is  injured  either  in  gunshot  or  stab  wounds  of  the 
forearm  or  in  incised  wounds  just  above  the  wrist.  The  motor  symptoms 
are  inability  to  flex  the  first  and  to  extend  the  second  and  third  phalanges 
of  the  fingers,  resulting  in  a  claw-hke  deformity  (Fig.  270).  The  thumb 
cannot  be  adducted  nor  can  the  wrist  be  drawn  toward  the  ulnar  side. 
As  a  rule,  there  is  anes- 
thesia only  over  the  little 
finger. 

The  median  nerve 
is  most  often  injured 
in  the  same  manner  as 
the  ulnar.  The  motor 
symptoms  are  inability 
to  flex  the  fingers  except 
the  ring  and  little  fin- 
gers. The  first  phal- 
anges of  the  fingers  can- 
not be  flexed  on  account 
of  paralysis  of  the  in- 
terossei  muscles.  The 
thumb  cannot  be  flexed 
or  abducted.  The  area 
of  anesthesia  is  usually 
very  small  and  most 
marked  over  the  volar 
surfaces  of  the  thumb, 
index,  and  middle  fin- 
gers. 

The  brachial  plexus  may  be  injured  (a)  through  tearing  of  one 
of  the  nerve- roots  close  to  its  emergence  from  the  spinal  cord.  These 
are  kno^^^l.  as  birth  paralyses.'  The  most  frequent  type  is  that  known 
as  the  Duchenne  (Fig.  271).  (b)  In  the  axilla,  as  the  result  of  disloca- 
tions or  gunshot  wounds,  (c)  In  fractures  and  other  injuries  of  the 
upper  arm  or  forearm  regions,  several  of  the  nerves  of  the  plexus  may 
be  involved  simultaneously.  Of  chief  interest  is  the  first  named  mode 
of  injury,  viz.,  traction  on  the  arm  during  ]:>irlh.  It  may  rcsuh  in  a 
subluxation  of  the  humerus  simulating  a  true  dislocation.     There  is 


Fig.  271. — Duchenne  Paralysis. 
Due  to  tearing  of   the  fifth  and  sixth   cervical  nerves  during 
birth,  close  to  their  point  of  emergence  from  the  spinal  cord.     (See 
text.)     The  position  of  the  hand  is  typical. 


438  THE   EXTREMITIES. 

inability  to  raise  the  arm  and  to  supinate  the  forearm,  the  latter  being 
held  pronated  with  a  drop-wrist  deformity. 

The  sciatic  nerve  and  its  branches  are  oftenest  injured  in 
the  lower  extremity.  The  main  trunk  may  be  severed  by  gunshot  or 
stab  wounds  of  the  thigh.  It  is  rarely  caught  by  a  callus  or  compressed 
by  fragments  at  the  time  of  injury,  in  supracondyloid  fractures  of  the 
femur.  Injuries  of  the  main  sciatic  trunk  are  quite  rare.  They  result  in 
the  absence  of  ability  to  use  any  of  the  muscles  below  the  knee  as  well  as 
inability  to  flex  the  knee-joint.  There  is  anesthesia  over  a  narrow  strip 
from  the  gluteal  fold  to  the  calf  of  the  leg,  which  then  spreads  so  as  to  em- 
brace all  of  the  leg  and  foot  except  an  area  along  the  inner  side  supplied 
by  the  internal  saphenous. 

The  external  popliteal  or  peroneal  nerve  has  been  caught  in  a  callus 
in  fractures  of  the  upper  end  of  the  fibula.  Injury  of  this  branch  re- 
sults in  inability  to  raise  the  outer  edge  of  the  foot  (paralysis  of  peronei), 
to  extend  the  toes,  or  to  flex  the  ankle.  There  is  an  area  of  anesthesia 
over  the  outer  half  of  the  front  of  the  les;  and  dorsum  of  the  foot. 


GENERAL    CONSIDERATIONS    OF    INJURIES    OF    THE    BONES. 

Injuries  of  the  bones  and  joints  of  the  extremities  are  so  often 
associated  that  they  will  be  considered  together.  Before  taking  up 
the  diagnosis  of  injuries  of  the  individual  bones  and  joints,  a  short 
review  of  their  more  general  characteristics  will  be  of  value. 

These  are,  as  a  rule,  of  two  varieties:  (a)  contusions;    (b)  fractures. 

Contusions  of  the  Bones. — These  are  the  result  of  direct  violence 
and  affect  the  periosteum.  For  this  reason  the  condition  is  often  spoken 
of  as  a  traumatic  periostitis.  The  periosteum  becomes  greatly  thickened 
and  very  tender.  The  diagnosis  can  readily  be  made  by  palpation  in 
the  more  superficial  bones  like  the  tibia,  where  it  most  frequently  occurs. 
At  times  the  swelling  in  the  periosteum  becomes  quite  locahzed 
and  fluctuates  as  the  result  of  the  liquefaction  of  a  hematoma.  In  some 
places,  like  the  neck  of  the  femur,  a  contusion  of  the  bone  may  be  fol- 
lowed by  softening  and  bending  of  the  bone.  (See  Coxa  Vara  Trauma- 
tica.) The  periosteum  remains  thickened  for  some  time  and  then  grad- 
ually resumes  its  normal  size. 

Fractures. — These  are  divided  according  to  various  criteria:  (a) 
Into  incomplete  and  complete,  according  to  whether  or  not  the  line  of 
fractures  passes  partly  or  entirely  through  the  bone,  (b)  Into  those 
which  occur  in  a  normal  bone  or  in  one  changed  in  its  structure  as  the 
result  of  disease  (pathologic  jractures).     (c)  Into  those  in  which  there 


GENERAL    CONSIDERATIONS    OF   INJURIES    OF    BONES. 


439 


is  no  communication  between  the  wound  in  the  skin  and  the  seat  of 
fracture,  called  simple  or  closed  jractures,  and  those  in  which  there  is 
such  a  communication,  called  compound  or  open  jractures.  A  third 
class  in  this  division  are  the  fractures  which  are  associated  with  injury 
of  nerves,  blood-vessels,  etc.,  and  called  complicated  fractures. 

A  fourth  class  also  belongs  to  this  group,  viz.,  the  gunshot  fractures. 

Incomplete  fractures  are  subdivided  as  follows:  (i)  Fissured.  (2) 
Greenstick  or  infraction  (Fig.  272).  (3)  Depressions.  (4)  Separation 
of  a  splinter  or  apophysis. 

Complete  fractures  are  subdivided  according  to  the  direction  of  the 
line  of  fracture  into : 


Fig.  272. — Various  Forms  of  Lines  of  Fracture. 
I,  Complete  transverse;  2,  longitudinal;  3,  oblique;   4,  spiral;   5,  incomplete  or  greenstick;    6,  subperiosteal. 


1.  Transverse.  These  are  rare  in  the  shaft  of  the  long  bones  and  are 
usually  found  in  the  lower  end  of  the  radius,  in  the  femur,  and  in  the 
short  bones. 

2.  Longitudinal.  Only  two  cases  have  been  reported  of  this  form 
of  fracture  line. 

3.  Oblique.  This  is  the  most  frequent  form  in  the  shaft,  but  occurs 
less  often  in  the  epiphysis.  If  in  the  latter  portion  of  the  bone,  it  is  either 
confined  to  it  alone  or  extends  from  it,  into  the  shaft. 

4.  Spiral.  This  was  formerly  considered  a  rare  form  of  fracture. 
With  the  more  systematic  use  of  the  .\'-ray  as  a  portion  of  the  routine 
of  diagnosis,  they  are  found  to  occur  far  more  frequently  than  was 
thoutrht  to  be  the  case.     Thev  are  usuallv  the  result  of  a  rotating  or 


440 


THE    EXTREMITIES. 


twisting  force  and  occur  oftenest  in  the  femur,  then  in  the  tibia,  humerus, 
and  fibula.  There  is  a  great  tendency  in  this  variety  to  penetrate  the 
skin. 

Number  of  Fragments. — In  the  majority  of  fractures  there  are 
only  two  fragments.  In  many,  however,  the  bone  is  broken  in  such  a 
manner  that  there  are  three  or  more  fragments.  If  each  of  the  latter  are 
large,  the  fracture  is  called  a  multiple  one;  but  if  they  are  quite  small,  as 
after  a  crushing  force,  the  fracture  is  termed  a  comminuted  one  (Fig.  340) . 
The  lines  of  fracture  may  resemble  a  letter  Y  or  T,  and  this  variety  is 
especially  apt  to  occur  at  the  epiphyseal  ends  of  certain  bones,  like  the 
humerus. 

Displacement  of  Fragments. — This  either  occurs  at  the  time  of  the 


Fig.  273. — Various  Forms  of  Displacement  or  Fragments  in  Fractures. 
I,  Lateral;  2,  angular;  3,  overriding;  4,  axio-rotation;  5,  overlapping  and  angular  combined;  6,  great  separa- 
tion of  fragments. 


accident  or  as  a  result  of  the  weight  of  the  hmb  or  the  action  of  muscles 
at  a  later  period.  The  various  forms  are:  (a)  Dislocatio  ad  axin  or 
angular  deformity.  This  seldom  occurs  alone,  but  usually  in  conjunc- 
tion with  one  or  all  of  the  other  varieties,  (b)  Dislocatio  ad  latus  or 
lateral  or  side-to-side  displacement  (Fig.  273).  This  rarely  occurs  in  a 
pure  form  except  in  transverse  fracture,  (c)  Dislocatio  ad  longitudi- 
nem  or  overlapping  or  overriding  of  fragments.  This  form  is  one  of 
the  most  frequent  results  of  oblique  fractures,  (d)  Dislocatio  ad  axin 
or  rotary  deformity.  In  this  variety  the  surfaces  of  the  bone  (Fig.  273) 
which  are  normally  in  apposition  have  rotated  upon  each  other. 

Seat  of  Fracture. ^A  fracture  may  (a)  involve  the  diaphysis  or 
shaft  of  a  long  bone,  or  (&)  the  epiphysis,  or  (c)  occur  through  the  epi- 
physeal cartilage  (epiphyseal  separation),  or  (</)  it  may  occur  through 


GENERAL    CONSIDERATIONS    OF   INJURIES    OF    BONES.  44I 

a  special  anatomic  point,  either  a  constriction  (neck  of  femur),  a  depres- 
sion (olecranon  fossa),  or  an  elevation  of  the  bone  (trochanter,  tube- 
rosities). 

Subperiosteal  Fractures. — A  special  variety  of  fracture  has  been 
recently  described  by  Hennig  ^  and  others  and  called  subperiosteal.  In 
these  the  diagnosis  can  only  be  made  at  the  time  of  the  injury  by  the  use  of 
the  x'-ray,  the  latter  mode  of  examination  often  revealing  a  fracture  passing 
through  the  entire  shaft  but  not  causing  any  injury  of  the  periosteum 
(Fig.  274).  It  is  important  to  recognize  these  on  account  of  the  resultant 
static  deformities,  such  as  flat-foot,  knock-knee,  coxa  vara  or  valga,  etc. 

Pathologic  or  Spontaneous  Fractures. — The  more  correct  term 
for  those  fractures,  which  occur  either  after  slight  or  practically  no  trauma 
in  bones  which  are  not  normal  in  structure,  is  pathologic  fracture.  One 
of  the  best  classifications  is  that  given  by  Grunert.^ 

I.  Fractures  Associated  with  Local  Lesions  of  Bone. 

A.  Tumors. 

1.  Primary  and  metastatic  sarcoma. 

2.  Metastatic  carcinoma. 

3.  Metastatic  thyroid  tumors. 

4.  Solid  enchondroma  and  benign  bone  cysts. 

5.  Echinococcus  cysts. 

B.  Inflammatory  processes. 

1.  Infectious  osteomyelitis  (pyogenic). 

2.  Tuberculosis  of  bone. 

3.  Syphihs. 

4.  Aneurysms. 

II.  Fractures  Associated  with  General  Diseases. 

A.  Neuropathies. 

1.  Tabes  dorsalis.  « 

2.  Syringomyelia. 

3.  Mental  diseases. 

B.  Senile  changes. 

C.  Exhausting  chronic  diseases. 

D.  Atrophy  due  to  non-use. 

E.  Scurvy. 

F.  Rickets  and  Osteomalacia. 

III.  Idiopathic  Friability  of  Bone  (osteoporosis,  fragilitas  ossium). 
It  is  of  importance  to  note  that  in  many  cases,  especially  in  those  of 

primary  sarcoma,  tabes,  syringomyelia,  etc.,  the  fracture  ma}'  be  the 
first  symptom.     In  general,  it  is  well  to  remember  that  a  fracture  occur- 

1  " Deutsche  Zeitschrift  fiir  Chirurgie,"  Bd.  Ix.w.  -Ibid.    Bd.  Ixxvi. 


442 


THE    EXTREMITIES. 


ring  after  the  use  of  a  minimum  amount  of  force  should  he  investigated 
as  to  the  possibility  of  its  being  of  a  pathologic  variety.  Union  may 
rarely  occur  in  the  ordinary  manner  after  these  fractures. 

The  Healing  of  Fractures. — Union  by  callus  formation  occurs  a 
little  more  rapidly  in  children  than  in  adults.  The  average  length  of 
time  required  for  firm  union  is  as  follows :     (a)  For  the  ribs — three  weeks ; 

(b)  for  the  forearm,  humer- 
us, clavicle,  bones  of  leg — 
four  to  five  weeks;  (c)  for 
the  femur — six  to  eight 
weeks. 

Simple  fractures  and 
compound  fractures  without 
infection,  heal  more  rapidly 
than  do  any  other  forms. 
Union  in  infected  compound 
fractures  is  often  greatly  de- 
layed, as  is  also  the  case 
with  fractures  involving  the 
larger  joints  (intraarticular). 
In  children  and  in  some 
adults  the  amount  of  callus 
formation  is  excessive.  In 
superficial  bones  like  the 
clavicle  such  an  exuberant 
callus  may  simulate  a  dis- 
placement of  fragment.  The 
callus  even  in  such  gradu- 
ally decreases  in  size  after  a 
short  period. 

Complications  of 
Fractures. — The  following 
are  the  chief  complications 
which  occur  during  the  clini- 
cal course  of  a  fracture : 

1.  Formation  of  biilltF  in  the  skin,  especially  in  fractures  of  the  leg. 

2.  Thrombosis  and  Embolism. — Not  infrequently,  a  thrombosis  of 
the  deep  veins  of  the  lower  extremity  occurs  in  fractures  of  the  bones 
of  the  leg,  as  well  as  in  those  of  the  patella  and  femur.  A  marked 
swelling  of  the  entire  limb  occurs,  which  is  far  greater  than  that  ordi- 
narily accompanying  such  a  fracture.     It  is  often  observed  for  the  first 


Fig.  274. — Subperiosteal  Fractures  (Lauenstein). 

A,  Of  the  lower  end  of  the  humerus;  a,  internal  condyle 
epiphysis;  b,  external  condyle  epiphysis.  The  arrow  in  all  of 
the  figures  points  to  the  seat  of  the  fracture.  B,  Subperiosteal 
fractures  of  the  ulna  and  radius;  C,  of  the  tibia  and  fibula  at 
middle  of  shaft;   D,  of  the  external  malleolus. 


GENERAL    CONSIDERATIONS    OF   INJURIES    OF   BONES.  443 

time  when  a  cast  or  other  retentive  apparatus  has  been  removed  and  the 
patient  allowed  to  get  about.  Quite  rarely  an  embolus  is  detached  and 
causes  marked  dyspnea,  rapid  pulse,  and  often  results  in  death  (Fig.  479). 

3.  Fat  Embolism. — Small  amounts  of  fat  are  washed  off  into  the  cir- 
culation with  every  fracture.  Quite  rarely  the  fat  emboli  lodge  in  the 
brain,  lungs,  and  kidneys,  and  give  rise  to  serious  symptoms,  and,  in 
some  cases,  death  occurs. 

In  the  lungs,  the  fat  infarcts  are  followed  by  edema  and  patches  of 
pneumonia.  The  symptoms  of  fat  embolism  are  usually  mistaken  for 
those  of  shock,  but  begin  a  little  later.  In  some  cases  pulmonary  symp- 
toms, such  as  rapid  breathing,  dyspnea,  and  coarse  rales  predominate. 


Fig.  275. — X-RAY  OF  Pseudarthrosis  of   Ulna   Following    Crushing   Injury  of  the  Entire  Upper 

Extremity. 

Taken  two  years  after  the  injury.     Notice  the  well-marked  lower  epiphyses  of  the  radius  and  ulna,  and  the 

silver  wire  in  siln  in  the  middle  of  the  shaft  of  the  humerus 

In  other  cases  cerebral  symptoms,  such  as  coma,  twitchings,  slow  ster- 
torous breathing,  etc.,  are  more  marked. 

4.  Injury  to  Blood-vessels. — These  have  been  described  on  page  429. 

5.  Injury  to  Nerves. — These  may  occur  either  at  the  time  of  the  injury, 
as  a  result  of  compression  or  laceration  of  the  nerve,  or  at  a  later  period, 
through  inclusion  of  the  nerve  in  a  callus.  The  recognition  of  these  has 
been  described  on  page  433.  - 

6.  Septic  Complications. — These  are  more  likely  to  occur  in  connec- 
tion with  compound  fractures  or  as  a  complication  of  the  gangrene  fol- 
lowing injury  of  the  vessels  of  the  limb. 

The  various  forms  of  infection  are  llie  same  as  tliose  wliich  compli- 
cate other  injuries  of  the  extremities,  and  are  described  on  page  529. 

7.  Osteomyelitis. — This  only  occurs  in  infected  compound  frac- 
tures and  will  be  described  later  (page  578). 


444 


THE   EXTREMITIES. 


8.  Delirium  Tremens  and  Traumatic  Delirium. — Hallucinations  of 
vision,  muscular  twitchings,  restlessness,  and  a  muttering  delirium  ac- 
companied by  rapid  heart's  action,  are  frequent  and  often  fatal  complica- 
tions of  fractures  in  alcoholics.  The  same  group  of  symptoms  may  occur 
in  individuals  not  addicted  to  drink,  and  the  condition  is  then  called 


\, 


Fig.  276. — X-RAY  OF  Pseudarthrosis  of  Middle  of  Shaft  of  Humerus  (G.  G.  Cottam). 


simple  or  traumatic  delirium.     The  latter  is  more  apt  to  occur  in  elderly 
persons  after  injuries. 

9.  Pulmonary  Edema  and  Pneumonia. — Pneumonia  appears  either 
as  an  early  comphcation  in  a  lobar  form,  or  late  as  a  hypostatic  pneu- 
monia. Both  are  more  apt  to  occur  in  elderly  people,  and  especially  in 
alcoholics.     The  lobar  or  early  type  runs  a  rapid  and  severe  course  with 


GENERAL    CONSIDERATIONS    OF   INJURIES    OF    BONES.  445 

high  fever  and  dehrium.  In  the  late  or  hypostatic  form,  the  symptoms 
appear  gradually  a  few  weeks  after  the  injury,  with  a  lower  range  of 
temperature,  stupor,  and  rapid  pulse. 

10.  Delayed  Callus  Formation  {Delayed  Union,  Fibrous  Union,  or 
Pseudarthrosis). — It  is  often  difficult,  if  not  impossible,  to  determine  the 
causes  of  this  complication. 

The  following  are  the  most  frequent  conditions:  (a)  The  union  is 
delayed.  Union  does  not  occur  within  the  ordinary  period,  but  eight 
to  twelve  weeks  after  the  fracture,  {h)  The  callus  does  not  go  on  to 
ossification  but  remains  soft,  (c)  The  fragments  are  held  together  by 
fibrous  tissue.     This  can  be  recognized  by  persistence  of  mobility  at 


Fig.  277. — View  of  Normal  Elbow-joint  of  a  Boy  Ten  Years  of  Age. 

R,  Shaft   of  radius;    U,  shaft  of  ulna;    H,  shaft  of  humerus;    i,  upper  epiphysis   of    radius  (capitellum); 

2j  epiphysis  which  forms  the  tip  of  the  olecranon  process;  3,  lower  epiphysis  of  humerus. 

the  point  of  fracture  and  the  fact  that  an  rv-ray  fails  to  show  a  shadow, 
indicating  ossification  of  the  callus  (Fig.  275).  {d)  A  false  joint  is 
formed  at  the  point  of  fracture.  The  fragments  are  bound  together  by 
fibrous  bands.  A  cavity  is  formed  in  which  the  rounded  ends  of  the 
bones  rub  on  each  other  (Fig.  276).  {e)  There  is  no  attempt  at  union  at 
all,  the  ends  of  the  bone  becoming  atrophied.  It  is  of  importance  to 
recognize  the  causes  of  non-union  or  delayed  union.  These  may  be 
divided  into  local  and  general. 

(i)  Local. — (a)  Imperfect  immobilization  of  fragments.  This  is 
one  of  the  most  frequent  causes. 

{b)  Great  separation  of  fragments. 


446 


THE    EXTREMITIES. 


(c)  Interposition  of  bone,  muscle,  or  tendon  between  the  fragments. 

(d)  Poor  blood-supply. 

(2)  General. — (a)  Neuropathic  causes,  e.  g.,  tabes,  syringomyelia, 
paralysis. 

(b)  Constitutional  causes,  e.  g.,  acute  infectious  diseases,  rickets, 
scurvy,  gout,  rheumatism,  chronic  nephritis,  diabetes,  alcoholism. 

II.  Faulty  or  Vicious  Union.  Union  with  Deformity,  or  Mal-union. 
— This  condition  may  be  recognized :  (a)  By  inspection  and  measurement 
of  the  limb  and  its  comparison  with  the  opposite  one.  (b)  By  palpation 
at  the  point  of  fracture,     (c)  By  x-rsiy  examination. 

The  most  frequent  causes  are :  lateral  displacement  with  overriding, 
marked  angular  displacement,  or  rotation  deformity. 


Fig.  278. — Method  of  Measuring  the  Circumference  of  the  Knee-joint. 

In  order  to  determine  any  increase  in  size,  due  to  the  presence  of  fluids,  tumors,  etc.     (See  text.)     The  method 

of  measurement  is  the  same  as  was  described  under  Fig.  259. 


The  Diagnosis  of  Fractures  in  General. — The  diagnosis  of  a  frac- 
ture of  one  of  the  bones  of  the  extremities  does  not  differ  from  that  of 
the  bones  previously  considered  in  the  chapters  on  the  head  and  thorax. 

The  following  routine  should  be  followed  in  the  examination  of  a  case : 

1.  History  of  how  the  accident  occurred. 

2.  Objective  signs,  such  as  deformity,  abnormal  mobility  and 
crepitus,  ecchymoses. 

3.  Subjective  symptoms,  such  as  pain,  loss  of  function  of  the  limb. 

4.  Examination  with  the  x-rsij. 

I.  History. — This  should  include  the  history  of  any  previous  ac- 
cidents which  may  have  caused  shortening  or  other  deformity  of  the  limb. 
An  exact  account  of  how  the  accident  occurred,  will  enable  one  to  judge 


GENERAL    CONSIDERATIONS    OF   INJURIES    OF    BONES.  447 

of  the  degree  of  force  employed  and  also  whether  the  mode  of  injury  was 
such  as  to  produce  a  fracture  by  direct  or  indirect  violence.  The  patient 
in  some  cases  may  call  attention  to  a  snapping  sound  when  the  bone 
broke,  followed  by  an  immediate  loss  of  function. 

2.  Objective  Signs. — A\\  of  these  may  be  present  in  a  case  or  one  or 
more  be  absent,  (a)  Deformity  is  determined  by  inspection,  measure- 
ment, and  palpation  of  the  limb.  It  must  not  be  forgotten  that  there  is 
often  a  quite  perceptible  (J  to  i^  inches)  difference  in  length  between 
opposite  limbs  (especially  in  the  lower),     (b)  Abnormal  mobility  of  the 


Fig.  279. — X-RAY  OF  Fracture  of  Clavicle  in  a  Boy  of  Eighteen. 
The  black  arrow  points  to  the  seat  of  fracture.     The  inner  fragment  has  been  pulled  upward  and  the  outer 
fragment  is  displaced  behind  the  inner  one.     The  clear  space  between  the  outer  end  of  the  clavicle  and  the 
acromion  process  is  due  to  the  lack  of  ossification  of  the  outer  epiphysis  of  the  former. 

bone  at  a  point  where  it  is  not  normally  present  is  one  of  the  valuable 
signs  of  fracture.  It  is  absent  in  impacted  and  incomplete  varieties  as 
well  as  in  the  intraarticular  form.  The  methods  of  determining  this 
sign  are  discussed  in  the  se-ction  on  special  fractures,  (c)  Crepitus. 
This  sign,  like  that  of  abnormal  mobility,  is  pathognomonic.  It  is  a 
grating  sensation  due  to  the  rubbing  of  the  broken  ends  upon  each  other. 
It  resembles  abnormal  mobility  in  being  absent  in  im])acted,  incomplete, 
and  articular  fractures.  It  is  also  aljsenl  when  a  considerable  separation 
or  displacement  of  the  fragments  is  present  or  when  some  foreign  sub- 
stance is  interposed,  like  muscle,  bone,  etc.,  between  the  broken  ends. 


448 


THE    EXTREMITIES. 


(d)  Ecchymosis,  when  it  appears  over  a  considerable  area  in  a  limb  which 
has  not  been  subjected  to  direct  violence,  is  of  great  value. 

3.  Subjective  Signs  of  Fracture. — (a)  Pain. — This  is  a  constant  ac- 
companiment of  a  fracture.  It  is  but  Httle  marked  if  there  is  considerable 
diastasis  of  fragments  and  if  the  fracture  is  impacted.  It  is  of  value  if  it  is 
quite  localized  in  fractures  sustained  by  indirect  violence,  especially  if  it 


Fig.  2S0. — Method  of  ExAiirNATiON  for  Fracture  of  the  Clawcle. 
The  patient's  left  arm  in  the  case  of  suspected  fracture  of  the  left  clavicle  is  allowed  to  rest  upon  the  left 
forearm  of  the  examiner,  so  that  the  patient's  arm  as  a  whole  can  be  raised  or  lowered  as  desired  to  determine 
a  false  point  of  motion,  which  the  examining  finger  or  lingers  of  the  opposite  or  right  hand  of  the  surgeon  can 
readily  feel. 


is  most  marked  on  movement  of  the  bone  or  pressing  the  ends  together. 
The  pain  of  a  fracture  lasts,  as  a  rule,  much  longer  than  that  of  con- 
tusions or  sprains.  In  fractures  due  to  direct  violence  the  injuries  of 
the  soft  parts  often  disguise  the  bone  pain. 

{h)  Loss  0}  Function  of  the  Limb. — In  many  cases  this  is  a  valuable 
sign  when  taken  in  conjunction  with  the  objective  ones.  In  the  majority 
of  individuals  there  will  be  inabihty  to  use  the  limb.     Exceptionally, 


GENERAL    CONSIDERATIONS    OE   INJURIES    OE    BONES.  449 

however,  one  will  find  persons  walking  about  on  a  fractured  leg  or  using 
a  broken  arm. 

4.  X-ray  Exaynination. — This  method  has  become  one  of  the  most  val- 
uable aids  in  the  diagnosis  of  injuries  of  both  bones  and  joints.  It  serves 
the  double  purpose  of  confirming  the  diagnosis  of  fracture  and  of  giving 
much  information  as  to  its  exact  nature.  The  jc-ray  should  not  be  em- 
ployed, however,  to  the  exclusion  of  the  other  objective  methods.  It  has 
the  great  advantage,  especially  in  the  case  of  fractures  in  deep-seated 
bones  and  in  those  close  to  joints,  of  enabling  a  diagnosis  to  be  made  at 
an  earlier  hour  and  with  less  manipulation  than  any  of  the  other  methods. 

Every  one  should  perfect  himself  in  the  examination  of  normal  limbs 
by  the  ordinary  methods  of  inspection,  palpation,  and  mensuration. 
The  examination  of  a  fractured  limb  for  deformity,  abnormal  mobihty, 


Fig.  281. — Dislocation  Upward  or  the  Acromial  End  of  the  Clavicle. 

The  arrow  points  to  the  depression  lying  between  the  bony  prominence,  caused  by  the  separation  of  the  acromia 

end  of  the  clavicle  from  the  acromion  process  of  the  scapula. 

and  crepitus  will  then  become  a  routine  procedure,  and  the  .T-ray 
will  occupy  its  true  position  of  confirming  and  amplifying  a  diag- 
nosis previously  made  by  the  other  methods.  It  is  essential  to  have  a 
knowledge  not  only  of  the  bony  landmarks,  etc.,  of  the  normal  limbs, 
but  of  the  skiagraphic  appearance  of  the  various  bones  and  joints  at  all 
ages. 

The  normal  epiphyseal  cartilage  looks  to  the  novice  like  a  fracture 
line  (Fig.  277),  so  that  one  of  the  most  valuable  contributions  to  skia- 
graphy during  recent  years  has  been  the  study  of  tlie  joints  from  infancy 
to  the  time  ossification  has  been  completed.^ 

It  must  be  remembered  that  the  amount  of  deformity  as  shown  by 
the  vT-ray  is  often  exaggerated  and  api)ears  far  greater  than  seems  to  ])c 
the  case  by  external  examination. 

^  "  For'tschritte  auf  deni  Gcbictc  der  Roentgen  strahlen." 
29 


45° 


THE    EXTREMITIES. 


For  information  in  regard  to  the  necessary  time  of  exposure,  the  angle 
at  which  the  picture  should  be  taken,  and  other  technical  points  one 
should  consult  the  special  treatises  on  this  subject. 

GENERAL  CONSIDERATIONS  UPON  INJURIES  OF  THE  JOINTS. 

An  injury  to  a  joint,  whether  the  force  be  applied  in  a  direct  or  an 
indirect  manner,  will  result  in  one  of  the  following  conditions:     (a)  A 


Fig.  282. — Method  of  Examination  to  be  Employed  in  Making  a  Differential  Diagnosis  Be- 
tween Dislocation  of  the  Shoulder-joint  and  Fracture  of  the  Anatomical  or  Surgical 
Neck  of  the  Humerus. 

This  illustration  shows  the  manner  of  examining  the  head  of  the  humerus  in  order  to  determine  whether 
it  has  its  normal  range  of  rotation,  thus  aiding  in  ascertaining  whether  the  head  of  the  humerus  lies  in  the 
glenoid  cavity.  The  method  consists  in  grasping  the  forearm  of  the  patient  close  to  the  wrist,  with  one  hand, 
while  the  head  of  the  humerus  is  held  between  the  thumb  in  front  and  the  remaining  fingers  behind,  i.  c,  along 
the  anterior  and  posterior  borders  respectively  of  the  deltoid  muscle. 


traumatic  arthritis;  (b)  a  penetrating  wound  of  the  joint;  (c)  a  dislo- 
cation. 

Traumatic  Arthritis. — The  term  sprain  was  formerly  apphed  to  all 
forms  of  non-penetrating  joint  injury,  except  dislocations.  With,  ad- 
vancing knowledge  of  both  the  pathologic  and  clinical  aspects  of  these 
injuries  it  seems  proper  to  speak  of  a  traumatic  arthritis.     This  term 


GENERAL    CONSIDERATIONS   UPON    INJURIES    OF    JOINTS.  45 1 

includes  injuries  to  all  of  the  structures  of  a  joint,  viz.,  synovial  mem- 
brane, capsule,  intraarticular  and  extraarticular  ligaments,  cartilages, 
etc.     In  joints  the  immediate  or  remote  consequences  of  injury  may  be: 

(a)  A  serous  or  hemorrhagic  effusion. 

(b)  Stretching  or  rupture  of  the  capsule. 

(c)  Stretching  or  rupture  of  one  or  more  hgaments. 


Fig.  283.— Method  of  Determining  the  Distance  Between  the  Acromion  Process  (.A-P)  and  the 
External  Condyle  of  the  Humerus  (£-C),  by  Means  of  a  Steel  Tape-measure. 
This  method  is  often  used  in  order  to  compare  the  humerus  of  one  side  to  that  of  the  other,  and  also 
for  the  purpose  of  determining  the  distance  between  these  two  points  in  the  diagnosis  of  dislocations  of  the 
head  of  the  humerus  or  fractures  of  the  surgical  neck. 

(d)  Complete  or  incomplete  dislocation  or  tear  of  the  intraarticular 
cartilages. 

(e)  Formation  of  free  joint  liodies. 

(/)  Recurrent  effusion  into  a  joint,  often  called  intermittent  hydrops. 
The  diagnosis  of  these  various  conditions  can  be  made  either  (a), 
shordy  after  the  injury  or  (h)   at  a  later  period. 


452 


THE   EXTREMITIES. 


(a)  Diagnosis  Shortly  after  Injury. — In  the  majority  of  joints,  a 
traumatic  arthritis  can  be  recognized  by  the  diffuse  pain  and  swelling 
which  sets  in  soon  after  the  injury.  The  presence  of  an  effusion  can  be 
recognized  in  the  more  superficial  joints,  by  the  obliteration  of  the  normal 
depressions,  by  fluctuation,  obtained  as  elsewhere,  by  bimanual  manip- 
ulation, and  in  the  knee,  by  the  baUottement  of  the  patella  (Fig.  438). 
The  measurement  of  the  circumference  of  the  joint  (Fig.  278)  should  be 
compared  with  that  of  the  opposite  side.     For  both  diagnostic  and  ther- 


FiG.  284. — X-RAY  OF  Fracture  of  Surgical  Neck  of  Humerus  in  a  Boy  Ten  Years  of  Age. 

The  arrow  points  to  the  line  of  fracture.  The  lower  fragment,  FD,  has  been  pulled  upward  and  outward 
through  the  action  of  the  deltoid  muscle,  so  that  it  forms,  as  is  frequently  the  case,  an  angle  with  the  upper  end 
of  the  bone  ;  FE,  upper  epiphysis  of  humerus  on  injured  side.  The  clear  line  just  below  it.  and  separating  it 
from  the  shaft  or  diaphysis.  is  due  to  the  fact  that  the  epiphyseal  cartilage  does  not  cast  a  shadow.  XE, 
Epiphysis  on  normal  side  :  ND,  diaphysis  or  shaft  on  normal  side. 


apeutic  purposes  it  is  often  advisable  to  aspirate  the  fluid  under  aU  pos- 
sible aseptic  precautions. 

In  deeper  joints,  like  the  hip  and  shoulder,  the  presence  of  an  ef- 
fusion is  dilficult  to  detect.  In  such  cases  one  can  judge  by  the  position 
in  which  the  hmb  is  held;  in  the  shoulder  this  is  adduction;  in  the  hip, 
flexion,  shght  abduction,  and  outward  rotation. 

In  the  majority  of  cases,  in  addition  to  the  eft'usion,  there  is  severe 
pain  which  may  be  localized  at  first  at  the  point  of  insertion  of  a  ligament. 


GENERAL    CONSIDERATIONS    UPON   INJURIES    OF    JOINTS. 


.453 


Pathologically  such  cases  are  accompanied  by  stretching  of  ligaments 
and  of  the  capsule.  These  are  the  cases  ordinarily  spoken  of  as  sprains. 
The  more  hemorrhagic  the  character  of  the  exudate,  the  greater  the 
probabihty  of  tears  of  the  capsule  or  hgaments,  or  of  a  fracture  extending 
into  the  joint. 

In  large  joints  hke  the  knee  a  diagnosis  of  a  tear  of  one  of  the  lateral 
ligaments  may  be  made  at  an  early  period  by  obtaining  abnormal  lateral 
mobihty  (Fig.  334). 

At  a  later  period,  when  the  effusion  has  disappeared,  one  must  bear 


f% 


1 IG.    2S5. 

Frequent  mode  of  displacements  of  fractures 
of  the  surgical  neck  or  of  the  humerus,  or  of  separ- 
ation of  the  upper  epiphysis  in  children.  L,  Lower 
fragment  (shaft),  displaced  inward  and  forward. 
Compare  with  Fig.  286. 


Fig.  2S6. 
Side  view  of  a  case  of  a  fracture  of  the  surgi- 
cal neck  of  the  humerus  showing  lower  fragment 
displaced    upward   and   forward   in   boy   of   ten. 
Compare  with  Fig.  285. 


in  mind  the  possibility  of  the  other  scqueke  of  a  traumatic  arthritis. 
These  sequelae  of  a  traumatic  arthritis  are : 

(a)  Rupture  oj  ligaments.  There  is  either  abnormal  mobility  or 
one  can  palpate  a  distinct  gap,  as  in  the  case  of  a  torn  ligamcntum 
patella;.  In  slight  tears  there  is  often  persistent  pain  referred  to  the 
point  of  insertion. 

ih)  Suhhixalion  oj  cartilages.  This  only  occurs  in  the  knee-joint 
as  a  result  of  forced  rotation,  involving  the  internal  meniscus  or  semi- 
lunar cartilage,  far  more  often  than  the  outer.     Complete  dislocation  has 


454 


THE   EXTREMITIES. 


never  been  observed.  The  diagnosis  is  seldom  made  at  the  time  of  the 
injur}^,  because  there  is  such  a  marked  effusion  that  palpation  is  impos- 
sible, and  the  case  is  treated  as  a  sprain.  At  a  later  period  there  is  a 
histor}'  of  sudden  attacks  of  pain  in  the  knee  and  inability  to  move  it, 
the  joint  being  often  fixed  in  a  position  of  sHght  flexion.  The  patient 
may  fall  to  the  ground  on  account  of  the  severe  pain  in  the  knee,  but 
usually  he  is  able  to  remain  erect,  but  cannot  support  himself  on  this  knee. 


Fig.  287. — X-RAY  OF  Impacted  Fracture  of  Surgical  Neck  of  the  Humerus  in  a  >Ian  of  THiRTy-Fi\'E. 
The  outlines  of  the  Kne  of  fracture  were  traced  in  ink  upon  the  x-Ta.y.     The  shaft  of  the  bone  has  become 

impacted  into  the  head. 


The  patient  often  experiences  a  sensation  as  though  sometliing  moved 
in  the  joint  or  snapped  back  with  a  distinct  cHck.  Some  patients 
observe  a  prominence  on  the  inner  or  outer  sides  of  the  joints. 

If  the  attacks  recur  frequently  they  are  milder  than  if  far  apart.  In 
the  latter  there  is  usually  more  or  less  effusion  present. 

The  patients  can  often  reduce  the  luxation  by  traction  on  the  leg  and 
by  rotation. 


GENERAL    CONSIDERATIONS    UPON   INJURIES   OF    JOINTS. 


455 


Vollbrecht  ^  has  described  two  groups  of  cases.  In  the  first  the 
original  injury  is  f  oho  wed,  after  a  long  confinement  to  bed,  by  the  typical 
attacks,  which  are  almost  continuous. 

In  the  second  group  there  is  an  apparent  recovery  from  the  first  ac- 
cident after  a  tedious  convalescence.  After  a  second  or  third  trauma 
the  typical  clinical  picture  sets  in.  One  of  the  most  characteristic 
objective  signs  is  the  interference  with  movements.  Both  flexion  and 
extension  are  actively  and  passively  interfered  with.  Another  confirm- 
atory sign,  if  found,  is  the 
palpation  of  a  movable 
body  in  the  gap  between 
the  femur  and  tibia. 
There  is  also  great  ten- 
derness over  the  dislocated 
meniscus. 

(c)  Free  bodies  in  the 
joints.  These  have  been 
variously  termed  floating 
cartilage,  loose  cartilage, 
joint  mice,  etc.  They  may 
result  from  the  application 
of  a  direct  (fall,  blow, 
crush)  or  of  indirect  force 
(sudden  tension  of  mus- 
cles or  ligaments,  torsion). 
They  may  occur  even  after 
very  slight  injury.  They 
occur  oftenest  in  the  knee- 
joint,  but  may  also  follow 
injury  to  the  shoulder, 
elbow,  and  wrist. 

The  most  characteris- 
tic symptom  is  the  so-called  "locking"  of  the  joint,  due  to  the  fact  that 
the  foreign  body  becomes  wedged  between  the  articular  surfaces.  There 
is  severe  pain  and  the  joint  is' suddenly  checked  in  its  range  of  motion,  so 
that  flexion  and  extension  cannot  be  executed.  Such  attacks  may  be 
accompanied  by  considerable  effusion.  Occasionally  the  free  body  can 
be  felt  and  held  between  the  fingers.  After  some  manipulation  the  float- 
ing cartilage  becomes  free  and  the  joint  can  be  used  again. 

The  typical  sym})toms  may  not  ap])ear  until  some  lime   (months  to 

^Bruns:  "Beitriigc  zur  klinisclicn  Chirurgic,"  Bd.  xxi. 


Fig.  288. — Posterior   View   of  Subcoracoid  Dislocation 

OF  Shoulder-joint. 
Same  case  as  shown  in  Fig.  289.     N,  Normal   shoulder;    D, 

dislocated  shoulder. 


456 


THE    EXTREMITIES. 


years)  after  the  injury  or  they  may  become  noticeable  immediately  after 
the  initial  symptoms  have  passed  away. 


GENERAL  CONSIDERATIONS  UPON  DISLOCATIONS. 

Dislocations  are  either  (a)  traumatic,  (b)  pathologic,  or  (c)  congenital 
in  origin.     They  may,  as  in  the  case  of  fractures,  be  either  simple  or 
compound,  according  to  whether  or  not  there  is  a  communication  be- 
tween a  wound  in  the 
skin  and  the  seat  of 
injury. 

If  a  dislocation 
tend  to  recur  from 
time  to  time  after 
having  been  reduced, 
it  is  termed  a  recur- 
rent or  habitual  dislo- 
cation. 

If  the  dislocation 
has  remained  unre- 
duced for  a  long  per- 
iod it  is  called  an 
inveterate  or  ancient 
or  unreduced  disloca- 
tion. 

The  pathologic 
dislocations  are  the 
result  either  of  {a)  an 
excessive  distention 
of  the  capsule,  (&)  a 
malformation  as  the 
result  of  disease  of 
the  articular  ends  of  the  bones  composing  the  joints.  In  both  cases, 
following  a  slight  trauma  or  independent  of  one,  the  dislocation  occurs. 
These  spontaneous  or  pathologic  dislocations  are  described  in  the  section 
on  diseases  of  the  joints. 

A  dislocation  may  be  complicated  by  injury  of  the  soft  parts  or  by  a 
fracture  involving  the  articular  bone  ends.  Compound  dislocations  are 
much  more  apt  to  be  complicated  by  injuries  of  vessels  and  nerves  than 
the  simple  are. 

The  recognition  ofan  injury  to  one  of  tJie  blood-vessels  of  the  limb 


Fig.  289. — Anterior  View  of  Dislocation  of  Shoulder-joint. 
Same  case  as  shown  in  Fig.  288.  N,  Normal  shoulder.  Note  the 
absence  of  prominence  of  the  acromion  process,  and  the  presence  of  the 
normal  convexity  of  the  shoulder.  D,  Dislocated  shoulder.  Note  the 
prominence  of  the  acromion  process,  and  the  flattening  of  the  shoulder 
due  to  absence  of  the  head  of  the  humerus. 


GENERAL    CONSIDERATIONS    UPON    DISLOCATIONS. 


457 


is  difficult.     Such  a  lesion,  as  a  rule,  occurs  oftenest  in  dislocations  of  the 
shoulder  and  knee.     The  signs  are: 

The  pulsations  of  the  artery  below  the  point  of  impingement  cannot 
be  felt,  the  Hmb  is  cold,  and  pressure  with  the  finger  shows  no  varia- 
tion in  color  when  the  finger  is  raised,  as  in  the  case  of  a  normal  limb. 
Gangrene  may  occur  immediately,  i.  e.,  within  a  few  days  or  only  grad- 
ually. If  the  artery  has  been  torn  a  large  pulsating  swelhng  rapidly 
forms  accompanied  by  signs  of  shock  and  internal  hemorrhage. 


AcP 


Fig.  290. — X-RAY  OF  Subcoracoid  Dislocation  of  tbe  Shoulder-joint. 
C,  Coracoid  process,  below  which  lies  the  head  of  the  humerus  (HH);   EGC,  empty  glenoid  cavity;  AcP, 
acromion  process  of  scapula.     Note  the  flattening  of  the  shoulder  below  the  acromion  process  due  to  the  ab- 
sence of  the  head  of  the  humerus. 

Injury  0}  nerves  as  a  result  of  dislocation  is  more  frequent  than  is 
injury  of  the  vessels.  Rupture  of  a  nerve  is  quite  rare,  while  a  contusion 
occurs  not  uncommonly. 

The  diagnosis  of  nerve  injury  can  be  readily  made  from  the  presence 
of  the  disturbances  of  sensation  and  motion  characteristic  of  such  injury. 
In  the  upper  extremity  paralysis  of  the  musculospiral  nerve  is  far  more 
frequent  than  is  that  of  all  the  other  nerves.  In  the  lower  extremity 
the  sciatic  and  anterior  crural  are  occasionally  involved. 


458 


THE   EXTREMITIES. 


Other  complications  of  dislocations  are:  (a)  injuries  of  the  skin  and 
other  soft  parts  in  compound  dislocations;  (b)  the  occurrence  of  atrophy 
of  the  muscles  proximal  and  distal  to  the  joint,  as  well  as  the  formation 
of  adhesions  within  the  joint;  (c)  fractures  involving  the  articular  ends  of 
the  bones  which  enter  into  the  formation  of  the  joint. 

Diagnosis  of  Dislocations  in  General. — As  in  fractures,  a  diag- 


5. 


Fig.  291. — Various  Forms  of  Fractures  of  the  Upper  End  of  the  Humerus  Associated  with  Dis- 
location OF  the  Head  of  Humerus  (Robert  Jones). 
I,  Split  fracture  of  shaft  of  humerus  with  subcoracoid  dislocation  of  head;  2,  obUque  fracture  of  upper 
end  of  humerus  with  subcoracoid  dislocation  and  separation  of  greater  tuberosity,  3,  fracture  cf  surgical  neck  of 
humerus,  with  dislocation  of  head;  4,  fracture  of  surgical  neck  of  humerus  with  displacement  upward  of  head, 
and  inward  of  shaft;  5,  subglenoid  dislocation  of  humerus,  with  separation  of  greater  tuberosity  to  outer  side, 
and  lesser  to  inner  side;  6,  subglenoid  dislocation  of  humerus,  with  fracture  of  anatomic  neck  and  separation 
of  greater  tuberosity.     This  illustration  was  made  from  skiagraphs. 


nosis  can  be  made  from  certain  objective  and  subjective  signs  taken  in 
conjunction  with  an  accurate  history  of  the  manner  in  which  the  accident 
occurred. 

The  examination  should  be  made  by  (a)  inspecting  the  limb  to  as- 
certain the  nature  of  the  deformity;  (b)  palpating  the  parts  to  learn  the 
relation  of  the  displaced  articular  ends  to  each  other;  (c)  measuring  the 


GENERAL    CONSIDERATIONS    UPON    DISLOCATIONS. 


459 


limb  with  the  aid  of  certain  fixed  anatomic  points  (Fig.  283);  {d)  an 
.T-ray  examination  if  necessary  to  confirm  the  diagnosis  of  dislocation 
and  to  ascertain  whether  there  is  a  complication  in  the  shape  of  a  fracture. 

The  objective  signs  of  a  dislocation  are : 

I.  Deformity. — The  position  in  w^hich  the  hmb  is  held  is  often  so 
characteristic  that  a  simple  inspection  will  indicate  the  condition  to  the 
experienced  eye.     In  stout  individuals  such  a  change  in  the  axis  of  a 


Fig.  292. — Lesions  to  be  Considered  in  Differential  Diagnosis  of  Shoulder  Injuries. 

A,  Acromion  process  of  scapula;  P,  coracoid  process  of  scapula;  S,  body  of  scapula;  C,  claN-icle;  H, 
humerus;  i,  normal  shoulder- joint,  showing  convexity  due  to  presence  of  head  of  humerus  in  glenoid  ca\Tty, 
and  to  deltoid  muscle;  2,  subcoracoid  dislocation  of  the  humerus;  3,  fracture  of  surgical  neck  of  humerus,  dis- 
placement of  lower  fragment  inward.  Note  the  flattening  of  the  normal  convexity  of  the  shoulder  in  both  2  and 
3.  4,  Fracture  of  neck  of  scapula,  permitting  humerus  to  drop;  5,  upward  dislocation  of  acromial  end  of 
clavicle;  6,  fracture  of  clavicle,  with  typical  displacement  of  fragments. 


limb  or  of  its  position  is  much  more  apt  to  l^e  overlooked  than  in  thinner 
individuals. 

In  general,  the  deformity  may  be  said  to  be  due  (a)  to  a  change  in  the 
direction  or  axis  (Fig.  288)  of  the  dislocated  bone  or  bones;  (&)  to  the 
abnormal  position  as  determined  by  palpation  (unless  too  much  swelling 
exists)  of  the  dislocated  articular  ends;  (c)  to  the  presence  of  an  empty 
joint  socket. 


460 


THE   EXTREMITIES. 


2" 


^  -^ 


JJ  >, 

-2  ^- 

II 

P 

-0   u 

0  ^ 
d   6 

0 

d 

0 

g 
0 

iH 

a  0 

!-l 

'Sh-S 


1:  0^  c 

c  3 

^  c  3  y 
, ,  ^  -^  4:, 

c  >  c 

d,   ge 

and  a 

in    a 

n  chil 

ductio 
ly  mc 
broke 

^  c«  >^:" 

-T3    C    CO 

0  p  .ti  "^ 

rt  0.2i 

e^-a:s^ 

T3          « 

Jess  in- 
net  ere 
lal    mo 
ess  ma 

ad  fixe 

ossible 

tuberc 

C-^   -tiyA 

=J    C1.-S 

p 


^1 


T3    o 


< 


P4      p< 


lU 

rQ 

0 

;y 

a. 

M-H 

Tl 

cd 

X) 

n 

-;5 

K 

<u 

01 

oi 

o  -a 


n) 

aj 

SJ 

^ 

C 

O. 

CJ 

CU 

J^ 

S3  S  ? 

^  ^  ^ 

a  g  fe 

'^  o  c 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


461 


2.  Dishirhance  of  Function  0}  the  Limb. — The  range  of  movement  of 
a  dislocated  joint  is  usually  limited.  If  any  movements  of  the  end  of 
one  of  the  bones  forming  the  articulation  are  felt,  they  are  at  a  point 
away  from  the  normal  joint. 

3.  Change  in  Length  of  the  Limb. — In  many  of  the  hip  and  shoulder 
dislocations  (Figs.  289,  329)  there  is  a  shortening  of  the  distance  between 
the  generally  accepted  lixed  bony  points  on  the  dislocated  side.  An 
absence  of  any  difference  in 

length  usually  means  only  a 
partial  dislocation  (subluxa- 
tion). 

4.  X-ray  Examination. — 
This  is  not  employed  as  often 
as  in  the  case  of  fractures, 
owing  to  the  fact  that  the  de- 
formity and  other  objective 
signs  usually  enable  a  diag- 
nosis to  be  made. 

It  should,  however,  be  used 
wherever  there  is  any  diffi- 
culty in  reduction  to  determine 
whether  a  fracture  coexists. 

When  the  patient  is  stout  or 
the  swelling  appears  early  and 
is  very  marked,  a  skiagraph  is 
of  the  greatest  possible  aid. 

Fig.  293. — Method  of  Examination  of  Fractures  of 

THE  Surgical  Neck  of  the   Humerus. 

The  left  hand  grasps  the  arm  close  to  the  point  of 

SPECIAL   FRACTURES   AND  fracture  in  the  case  of  the  right  arm,  and  «ce  versa  in  the 

_^.j.„-.  _  _  .  _..__-„  case  of  the  left  arm,  while  the  forearm  of  the  patient  is 

UiiLULAliUiNi).  allowed  to  rest  upon  the  outstretched  palm  of  the  exami- 

ShoUlder  Region. In  the  "'^''-     ^^  carrying  the  forearm  and  lower  fragment  alter- 

_  nately  away  from  and  toward  the  body  the  false  point  of 

examination  of  a  patient  to  as-  motion  and  crepitus  can  readily  be  elicited. 

certain  the  nature  of  an  injury_ 

to  the  shoulder  region,  the  following  conditions  must  be  thought  of  and 

eliminated  by  exclusion  in  the  order  named : 

1.  Fractures  of  the  clavicle  (most  often  in  middle  iliird). 

2.  Dislocations  of  the  clavicle  at  the  sternal  or  acromial  ends  (latter 
most  common). 

3.  Fractures  of  the  scapula  (most  often  in  acromion  process). 

4.  Fractures  of  the  upi^er  end  of  Inimerus  (usually  al  surgical  neck). 

5.  Dislocation  of  the  shoulder-joint  (subcoracoid  most  frequent). 


462 


THE   EXTREMITIES. 


The  principal  diagnostic  features  of  these  injuries  follow: 
I .  Fractures  of  the  Clavicle. — x^bout  one-half  of  these  occur  in  the 
middle  third  of  the  bone,  and  a  third  of  the  remainder  at  the  junction  of 
the  outer  and  middle  thirds  of  the  bone.  Incomplete  fractures  of  the 
greenstick  variety  are  quite  common  in  children,  and  not  infrequently 
escape  recognition  until  a  callus  has  begun  to  form.  Fractures  of  the 
middle  third,  Avhen  complete  and  associated  with  displacement  of  frag- 
ments (Fig.  279),  are  easily 
diagnosed.  On  passing  the 
finger  along  the  anterior  or 
upper  surfaces,  the  projec- 
tion of  the  overlapping  frag- 
ments, or  the  formation  by 
them  of  an  angle  directed 
backward,  can  be  readily 
--^  felt.      The   other   signs   of 

fracture,  crepitus  and  a  false 
point  of  motion,  can  be 
demonstrated,  if  necessary, 
^*^;*!  by  alternately  raising  and 
lowering  the  arm  when 
grasped  at  the  elbow- joint 
(Fig.  280).  At  times  it  is 
necessary  to  draw  the  shoul- 
der back  in  order  to  obtain 
crepitus. 

The  diagnosis  of  frac- 
tures which  are  complete 
but  not  associated  with  dis- 
placement, as  well  as  of 
greenstick  (incomplete) 
fractures,  is  not  as  easy. 
In  such  cases  one  is  guided  by  the  history  of  the  mode  of  injury  (fall 
upon  the  shoulder  or  outstretched  hand)  and  the  results  of  palpation. 
The  latter  shows  a  great  tenderness  at  the  point  of  fracture  and  there 
is  pain  on  raising  the  arm  voluntarily  or,  as  shown  in  Fig.  280,  it  is 
referred  to  this  spot.  In  many  cases  a  shght  elevation  of  the  surface 
of  the  bone  is  present  at  the  point  of  greatest  tenderness. 

Multiple  and  comminuted  fractures  of  the  clavicle  are  quite  rare,  and 
can  be  recognized  by  feeling  the  separate  fragments  and  by  the  use  of 
the  a--ray  (Fig.  279). 


Fig.  2g4. — Method  of  Examination  of  a  Fracture  of  the 
Upper  or  Middle  Third  of  the  Shaft  of  Humerus. 
The  right  hand  in  the  case  of  an  examination  of  the  left 
humerus  is  placed  over  the  seat  of  fracture,  the  elbow  is  per- 
mitted to  rest  upon  the  opposite  hand,  the  arm  being  moved 
alternately  toward  and  away  from  the  body  in  order  to  deter- 
mine abnormal  mobility  and  crepitus. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


463 


Fractures  near  the  sternal  or  clavicular  ends  of  the  cla\'icle  are  often 
associated  with  considerable  displacement  of  fragments  (Fig.  279)  and 
may  simulate  a  dislocation  of  the  clavicle.  In  the  case  of  a  fracture  there 
is  distinct  crepitus,  and  the  point  at  which  abnormal  mobility  exists  is  situ- 


'^, 


Fig.  295. — X-RAY  OF  Pseudarthrosis  of  Fracture,  Middle  of  Shaft  of  Humerus,  the  Exterior  Pic- 
ture OF  Which  is  Shown  in  Fig.  293. 

This  -v-ray  was  taken  five  months  after  the  injury;  the  .r-ray  shows  practically  no  callus  formation  (fibrous 

union). 


ated  close  to  the  sternoclavicularand  acromioclavicular  joints  respectively. 
The  joints  themselves  arc  found  to  be  intact  l^y  placing  a  finger  over  them 
while  the  arm  is  alternately  raised  and  lowered.  A  familiarity  with  the 
anatomic  relations,  as  gained  by  palpation  on  normal  subjects  during  Hfe, 
is  of  invaluable  aid  in  the  diagnosis  of  injuries  of  the  bones  and  joints. 


464 


THE   EXTREMITIES. 


In  cases  of  doubt,  especially  if  the  injury  is  at  the  acromioclavicular 
joint,  a  skiagraph  should  be  taken.  In  the  greenstick  fractures  of  chil- 
dren the  callus  is  usually  excessive  in  size  for  the  first  eight  to  twelve 
weeks  and  then  gradually  disappears. 

2.  Dislocations  of  the  Clavicle. — Dislocations  of  the  sternal  end  are 
much  rarer  than  are  those  of  the  acromial  end.  Dislocation  at  the  sterno- 
clavicular joint  occurs  in  three  forms :  (a)  a  forward,  which  is  the  most 
common;  (h)  a  backward,  and  (c)  an  upward.  In  each  of  these  the 
diagnosis  should  be  readilv  made  unless  great  swelling  exists.     The  unat- 


FiG.  296. — Ankylosis  of  Shoulder-joint  (Partial),  Following  Fracture  or  the  Upper  Third  of  the 

Humerus. 
The  left  arm  is  shown  so  that  it  can  be  compared  with  the  right  or  injured  arm.     The  amount  of  abduction 
of  the  left  or  uninjured  arm  was  normal.     On  the  right  or  injured  side  the  arm  could  be  abducted  only  to  the 
distance  of  about  forty-five  degrees  from  the  body.    The  illustration  also  shows  a  well-marked  flexion  contrac- 
ture   due  to  non-use  of  the  elbow-joint. 


tached  end  of  the  clavicle  is  felt  either  in  front,  behind,  or  above  its 
normal  position.  In  addition,  there  is  locahzed  pain,  and  in  the  back- 
ward variety  there  may  be  signs  of  pressure  upon  the  trachea  or  upon 
the  vessels  at  the  lower  part  of  the  neck. 

Dislocation  at  the  acromioclavicular  joint  occurs  (a)  upward  (supra- 
acromial);  (b)  downward  and  backward  (subacromial),  and  (c)  down- 
ward and  forward  under  the  coracoid  process  (subcoracoid).  Of  these, 
the  second  and  third  are  so  rare  that  one  need  but  consider  the  first 
variety  clinically.  This  may  exist  in  either  an  incomplete  or  a  com- 
plete form.     In  the  former  the  clavicle  can  be  felt  to  be  raised  slightly 


SPECIAL    FRACTURES    AND   DISLOCATIONS.  465 

above  the  level  of  the  acromion  and  can  be  forced  back  in  place  by  press- 
ure. Upon  removing  the  finger  the  bone  springs  back  again.  In  the 
complete  variety  there  is  quite  a  gap  to  be  felt  between  the  outer  end  of 
the  clavicle  and  the  acromion  process  (Fig.  281).  By  pressure  upon  the 
clavicle  the  latter  can  be  brought  toward  the  acromion,  but  can  only  be 
held  there  with  difficulty.  The  amount  of  functional  disturbance  and 
local  pain  varies  greatly,  being  very  marked  in  some  cases. 

3.  Fractures  of  the  Scapula. — Fractures  of  this  bone  may  occur 
either  through  the  body,  inferior  and  superior  angles,  spine,  acromion, 


2. 


ill 


-9* 


Fig.  297. — Most  Frequent  Forms  of  Injury  of  the  Bones  Comprising  the  Elbow- joint. 

iJ",  Humerus;  i?,  radius;  f ,  ulna,  i,  Supracondyloid  fracture  of  humerus;  2,  epiphyseal  separation  of 
the  lower  end  of  humerus;  3,  backward  dislocation  of  both  bones  of  forearm;  4,  fracture  of  internal  epicondyle 
(a)  and  of  internal  condyle  itself  (i);  5,  fracture  of  external  epicondyle  (a)  and  of  external  condyle  (6);  6, 
T-shaped  fracture  of  lower  end  of  humerus;  7  fracture  of  olecranon  and  of  neck  of  radius;  8,  fracttire  at 
jimction  of  upper  and  middle  shafts  of  ulna,  combined  with  forward  dislocation  of  head  of  radius. 

coracoid,  surgical  neck,  and  glenoid  cavity.  Of  these,  all  except  fractures 
of  the  body,  acromion,  and  spine  are  so  rare  as  to  be  of  little  importance 
clinically.  Fractures  of  the  body  may  be  suspected  from  the  history  of 
a  blow  or  other  direct  violence  over  the  scapular  region,  followed  by  pain 
localized  over  the  body  of  the  scapula  and  increased  by  any  movement  of 
the  arm.  The  outline  of  the  bone  can  be  felt  to  be  irregular,  and  by 
grasping  the  lower  angle  one  can  obtain  crepitus  and  abnormal  mobility. 
In  many  cases  this  is  either  difficult  or  impossible,  on  account  of  the  pain 
and  swelling,  so  that  reliance  must  be  placed  upon  feeling  an  irregularity 
and  the  presence  of  severe  pain  on  pressure  and  movement. 


466 


THE    EXTREMITIES. 


Fractures  of  the  acromion  process,  like  those  of  the  body  of  the  bone, 
are  very  difficuh  to  recognize  by  palpation.  The  use  of  the  :x;-ray  has 
been  of  great  aid  in  the  diagnosis  of  these  fractures.  On  passing  the 
finger  backward  from  the  tip  of  the  process  one  can  at  times  feel  a  de- 
pression corresponding  to  the  displacement  of  the  fragments.  Crepitus 
and  a  point  of  abnormal  mobility  are  obtained  by  alternately  raising  and 
lowering  the  arm.  which  is  grasped  at  the  elbow  (Fig.  293),  while  the  finger 

is  placed  over  the  acromion 
process.  There  is  usually  in- 
ability to  raise  the  arm. 

The  most  frequent  loca- 
tions of  these  fractures  are 
either  at  the  base  or  tip  of  the 
acromion  process.  Fractures 
of  the  surgical  neck  of  the 
scapula  are  very  rare.  They 
simulate  dislocations  of  the 
shoulder  on  account  of  the 
dropping  of  the  humerus  (Fig. 
292)  with  marked  concavity 
below  the  acromion  process. 
When  the  arm  is  raised  the 
latter  deformity  disappears, 
the  manipulation  being  ac- 
companied by  crepitus.  An 
.v-ray  will  readily  clear  up  the 
diagnosis. 

4.  Fractures  of  the  Up- 
per End  of  the  Humerus. — 
Before  attempting  the  diag- 
nosis of  an  injured  shoulder 
one  should  accustom  one's  self,  either  by  previous  training  or  ex- 
amination of  the  normal  shoulder,  to  palpate  the  most  important 
points  in  the  applied  or  clinical  anatomy  of  the  normal  shoulder. 
These  are:  (a)  palpation  of  the  acromion  process  and  its  relation 
to  the  clavicle;  (b)  determination  of  the  fact  that  the  head  of  the 
humerus  rotates  in  the  glenoid  cavity  (Fig.  282);  (c)  palpation  of  the 
normal  convexity  of  the  shoulder  due  to  the  deltoid  muscle  and  the 
head  of  the  humerus;  (d)  measurement  from  the  tip  of  the  acromion 
process  to  the  external  condyle  of  the  humerus  (Fig.  283);  {e)  extent  of 
normal  movements  of  the  shoulder-joint  (abduction,  adduction,  ex-ten- 


FiG.  298. — Typical  Swelling  of  Elbow-joint  in  a  Child 
OF  Five,  Following  a  Fall  upon  the  Arm,  Illus- 
trating THE  Difficulties  of  Diagnosis.     (See  text.) 


SPECIAL    FRACTURES    AND   DISLOCATIONS.  467 

sion  in  a  forward  and  backward  direction) ;  (/)  study  of  an  x-tslj  of  a 
normal  child's  and  adult's  shoulder-joint. 

The  possible  injuries  at  the  upper  end  of  the  humerus  which  must  be 
taken  into  consideration  are:  (i)  Fracture  of  the  anatomic  neck  alone 
or  with  fracture  through  the  tuberosities;  (2)  epiphyseal  separation; 
(3)  fracture  of  the  surgical  neck;  (4)  impacted  fracture  of  the  surgical 


Fig.  2gg. — Method  of  Determining  the  Relation  of  the  Three  Bony  Points  at  the  Back  of  the 
Elbow  in  Examinations  for  Fractures  or  Dislocations  of  the  Bones  Which  Form  the  Elbow- 
joint. 

In  the  case  of  an  examination  of  the  left  elbow,  as  shown  here,  the  patient's  left  forearm  is  allowed  to  rest 
upon  the  left  forearm  of  the  examiner,  while  the  latter's  right  hand  supports  the  elbow  in  such  a  manner  that 
the  thumb  rests  upon  the  external  condyle,  the  middle  finger  upon  the  internal  condyle,  and  the  index-finger 
upon  the  tip  of  the  olecranon.  The  relation  of  these  three  points  is  shown  in  the  illustration  when  the  elbow 
is  flexed,  that  is,  the  tip  of  the  olecranon  lies  a  little  below  the  dotted  line  joining  the  two  condyles.  When 
the  arm  is  extended  the  tip  of  the  olecranon  lies  either  in  this  line  or  above  it. 

neck;  (5)  fracture  of  the  uppe'r  end  of  the  humerus,  combined  with 
dislocation  of  the  head. 

Fracture  oj  the  anatomic  neck  is  almost  always  associated  with 
fracture  of  the  tuberosities  and  cannot  be  distinguished  clinically  from 
fractures  of  the  surgical  neck  except  by  an  x-ray  examination.  Isolated 
fractures  of  the  tuberosities  arc  also  rare.  Those  of  the  greater  tuber- 
osity usually  accompany  a  dislocation  of  the  shoulder.  When  it  occurs 
independently  of  such  an  injury  the  diagnosis  may  be  made  if  one  can 


468 


THE   EXTREMITIES. 


palpate  a  loose  fragment  corresponding  to  the  greater  tuberosity  and  can 
cause  pain  by  pressure  and  upon  rotating  the  arm  outward. 

Lorenz  ^  reported  a  case  of  fracture  of  the  lesser  tuberosity  which 
followed  forced  outward  rotation  of  the  arm.  Sixteen  months  after  the 
injury  when  first  examined  by  Lorenz  internal  rotation  was  impossible,  and 

on  palpation  a  sharp  edge  of 
bone  was  evident  at  the  location 
of  the  lesser  tuberosity. 

Epiphyseal  separation  at  the 
upper  end  of  the  humerus  oc- 
curs most  frequently  between 
the  ages  of  nine  and  sixteen. 
The  diagnosis  in  cases  without 
displacement  is  very  difficult 
and  can  be  made  only  by  the 
presence  of  pain  on  pressure,  or 
pain  and  soft  crepitus  upon  ro- 
tation of  the  humerus,  localized 
at  the  level  of  the  epiphyseal  car- 
tilage. In  some  of  these  cases 
displacement  is  likely  to  take 
place  after  a  few  days  if  the  arm 
is  not  immobilized. 

In  cases  with  either  primary 
or  the  above  referred  to  secon- 
dary displacement,  the  diagnosis 
can  be  made  by  palpation,  if  the 
swelling  is  not  too  great,  or  by 
an  5c-ray  examination. 

On  palpation  one  feels  the 
normal  convexity  of  the  shoul- 
der, due  to  the  fact  that  the 
head  is  still  in  the  glenoid  cav- 
ity, thus  serving  to  distinguish 
the  injury  from  a  dislocation. 
The  upper  end  of  the  diaphysis 
or  shaft  is  to  be  felt  over  the  coracoid  process  an  inch  or  more  below 
the  acromion.  This  point  rotates  with  the  remainder  of  the  shaft  and 
can  be  rendered  more  prominent  by  raising  the  shoulder.  The  displace- 
ment is  usually  forward  and  inward  (Fig.  285).     Upon  manipulation 

■  1  "Deutsche  Zeitschrift  fur  Chirurgie,'\Bd.  Iviii,  S.  523. 


Fig.  300. — Posterior  View  of  Normal  Adult  El- 
bow-joint (ac-ray). 
H,  Humerus;  R,  radius;  U,  ulna.  The  arrow  points, 
to  the  clear  space  seen  in  such  views,  which  corresponds 
to  the  olecranon  fossa,  and  is  not  to  be  interpreted  as 
a  fracture. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


469 


crepitus  can  frequently  be  felt  where  the  head  and  upper  end  of  the 
displaced  shaft  meet. 

Fractures  0}  the  surgical  neck  of  the  humerus  include  all  frac- 
tures in  the  upper  fourth  of  the  bone  below  the  epiphyseal  line.  As 
in  the  cases  of  epiphyseal  separation,  the  diagnosis  is  difficult  or  easy 
according  to  the  degree  of  displacement.  In  both  instances  the  head  of 
the  bone  is  found  by  grasping  it  between  the  lingers.     On  rotating  the 


I 

^^V 

1        »   ^        -*f'J 

I 

H_  w 

w         » 

\ 

^^^H 

^ 

\  - 

V 

"■*"*'  '                    ^  - 

1^ 

"*    -a 
t 

'                           1 

Fig.  301. — Method  of  Palpation  of  Head  of  Radius. 
In  examining  the  head  of  the  radius  of  the  left  arm  as  shown  in  the  illustration,  the  surgeon  grasps  the 
patient's  hand  with  his  own  left  hand  as  though  he  were  shaking  hands.  The  surgeon  then  grasps  the  head 
of  the  radius  (which  is  to  be  found  just  beneath  the  external  condyle  of  the  humerus)  between  the  thumb  and 
index-finger  of  the  right  hand.  The  patient's  forearm  is  alternately  supinated  and  pronated  while  the  sur- 
geon's right  hand  can  feel  the  rotation  of  the  head  of  the  radius.  On  the  right  side  the  hands  of  the  examiner 
are  simply  reversed. 


shaft  in  cases  without  displacement,  the  head  fails  to  participate  in  the 
movement,  and  there  is  pain,  crepitus,  and  abnormal  mobility  at  the 
point  of  fracture. 

If  impaction  of  the  fragments  exists,  all  of  these  signs  are  absent  and 
the  diagnosis  can  only  be  made  from  the  histor}'  of  the  mode  of  injury, 
the  presence  of  locaHzed  pain  upon  rotation,  loss  of  function  of  the  arm, 
and  an  x-ray  (Fig.  287).     In  cases  with  moderate  or  more  marked  dis- 


470 


THE    EXTREMITIES. 


placement  the  ends  of  the  fragments  and  their  relation  to  each  other  can 
be  felt  in  thin  subjects  by  following  the  shaft  upward.  Abnormal 
mobility  and  crepitus  are  usually  quite  easily  elicited.  There  is  often 
a  change  in  the  axis  of  the  arm  (Fig.  288),  as  in  a  dislocation,  but 
the  presence  of  the  head  in  the  glenoid  cavity  and  of  the  normal  contour 
or  convexity  of  the  shoulder  will  exclude  dislocation.     The  coexistence 


Fig. 302. — Method  of  Examining  the  Lower  End  op  the  Humerus  in  Cases  of  Fracture  at  this  Point. 
The  forearm,  when  one  is  examining  the  right  arm,  is  grasped  by  the  left  hand,  the  hand  of  the  patient  be- 
ing allowed  to  rest  upon  the  forearm  of  the  examiner,  while  the  right  hand  of  the  examiner  grasps  the  region 
of  the  lower  end  of  the  humerus.     For  the  examination  of  the  left  humerus,  the  hands  should  be  reversed. 


of  fracture  of  the  surgical  neck  and  dislocation,  of  the  shoulder  is  referred 
to  later. 

Dislocations  of  the  shoulder- joint  occur  in  the  following  direc- 
tions : 

1.  Forward  or  anterior — Subcoracoid  (quite  common  form);    sub- 
clavicular (rare). 

2.  Downward — Subglenoid  (rare). 

3.  Backward  or  posterior — subacromial  (rare) ;  subspinous  (very  rare). 

4.  Upward — Supraglcnoid  (very  rare). 


SPECIAL   FRACTURES    AND    DISLOCATIONS.  471 

For  ordinary  diagnostic  purposes  one  need  consider  only  the  sub- 
coracoid  and  subglenoid.  The  patients  incline  the  head  toward  the 
injured  side  and  complain  of  pain  in  the  shoulder  and  along  the  entire 
arm.     The  objective  signs  of  a  suhcoracoid  dislocation  are: 

(fl)  The  normal  convexity  is  lost  and  one  can  see  a  distinct  flat- 
tening or  even  a  depression  below  the  acromion  process  (Fig.  288) 
when  looked  at  while  standing  in  front  of  or  behind  the  patient. 

(h)  There  is  a  prominence  below  the  outer  end  of  the  clavicle  at  the 
coracoid  process. 

(c)  The  arm  is  abducted,  the  elbow  often  being  three  to  four  inches 
from  the  chest. 


Fig.  303. — Deformity  Following  Supracondyloid  Fracture  of  the  Humerus. 
The  illustration  shows  how  the  lower  fragment,  HL,  is  displaced  backward  and  upward,  and  the  upper 
fragment  downward  and  forward,  HU,  causing  it  to  become  prominent  at  the  bend  of  the  elbow.     (See  text.) 
R,  Radius;  U,  ulna,     i,  Upper  epiphysis  of  radius;   2.  epiphysis  corresponding  to  olecranon  process;   3,  lower 
epiphysis  of-  humerus. 

{d)  The  axis  of  the  humerus  is  changed  so  that  instead  of  being 
nearly  parallel  with  that  of  the  opposite  side,  an  imaginary  line  dra^vn 
through  the  dislocated  humerus  meets  that  of  the  corresponding  bone 
of  the  opposite  arm  a  little  beyond  the  head  (Fig.  289). 

(«)  There  is  a  lengthening  of  the  arm  as  measured  from  the  acro- 
mion to  the  external  condyle  (Fig.  283). 

(/)  On  palpation  one  feels  the  depression  below  the  acromion  and 
the  empty  glenoid  cavity  is  felt  by  pushing  the  fingers  in  deeply. 

ig)  The  head  can  be  felt  beneath  the  coracoid  process. 

{h)  The  arm  is  more  or  less  fixed,  permilting  of  Imt  slight,  if  any, 
abduction  or  rotation. 


472 


THE    EXTREMITIES. 


The  symptoms  of  a  subglenoid  dislocation  are  that  the  head  can 
be  felt  through  the  axilla,  lying  beneath  the  glenoid  cavity  and  the 
abduction  of  the  arm  is  more  marked.  In  the  subclavicular  form,  the 
head  is  to  be  felt  at  the  point  where  the  pectorahs  major  and  deltoid 
meet  and  the  arm  is  greatly  adducted.  In  the  subacromial  and  sub- 
spinous or  backward  forms,  in 
addition  to  the  flattening  of  the 
shoulder  and  the  empty  glen- 
oid cavity,  one  can  see  and 
feel  the  head  of  the  humerus 
beneath  the  prominent  acro- 
mion process  or  even  further 
back. 

Fractures  of  the  Shaft 
of  the  Humerus. — In  this 
are  included  all  fractures  oc- 
curring between  the  insertion 
of  the  deltoid  above  and  the 
upper  portion  of  the  supra- 
condyloid  ridges  below.  The 
diagnosis  can  be  made  in  the 
majority  of  cases  by  manipu- 
lation of  the  arm  (Fig.  294), 
especially  if  there  is  some  de- 
gree of  dislocation.  The  or- 
dinary signs  of  fracture,  such 
as  crepitus,  abnormal  mobil- 
ity, loss  of  function,  locahzed 
pain,  are  all  quite  marked. 
If  there  is  considerable  dis- 
placement of  fragments,  the 
lower  portion  of  the  arm 
may  form  an  angle  with  the 
upper  and  the  ends  of  the 
fragments  are  visible  and 
easily  felt. 
The  greatest  interest  in  connection  with  fractures  of  the  shaft  of 
the  humerus  is  in  connection  with  injuries  of  the  musculospiral  nerve 
or  laceration  of  the  brachial  artery.  The  diagnosis  of  these  com- 
plications has  been  previously  discussed  (page  434).  Delayed  union 
is  very  frequent  in  this  form  of  fracture  and  can  be  recognized  by  the 


Fig.  304. — X-RAV  of  Fracture  Through  the  Lower  Epi- 
physis OF  THE  Humerus  in  a  Child  of  Three. 
The  outlines  of  the  bones  have  been  strengthened  by 
tracing  them  in  black.  RS,  Shaft  of  radius;  R,  upper  epi- 
physis (capitellum)  of  radius;  US,  shaft  of  ulna;  E,  lower  epi- 
physis of  humerus  displaced  inward;  H,  shaft  of  humerus. 


SPECIAL    FR.A.CTURES    AND    DISLOCATIONS. 


473 


persistence  of  abnormal  mobility  and  the  absence  of  ossification  (Fig. 
295),  as  shown  in  a  skiagraph. 

Injuries  in  the  Vicinity  of  the  Elbow-joint.— In  the  examina- 
tion of  a  person  suffering  from  an  injury  of  the  elbow-joint  the  fol- 
lowing possible  lesions  must  be  thought  of  and  one  excluded  after 
the  other  by  a  systematic  examination,  combined,  if  required,  with 
the  use  of  the  rv-ray. 

T.  Fractures  of  lower  end  of  humerus. 

(a)  Supracondyloid  fracture  (more  or  less  transverse  of  shaft  above 
condyles). 

(b)  T  or  Y  fractures. 

(c)  Epiphyseal  separation. 

(d)  Fractures  of  external  or  internal  condyles  and  epicondyles. 

2.  Lesions  of  the  radius  and 
ulna: 

(a)  Dislocation  backward  of 
radius  and  ulna. 

(b)  Fracture  of  upper  third  of 
ulna  with  or  without  dislocation 
forward  of  radius. 

(c)  Dislocation  forward  of 
upper  end  of  radius. 

(d)  Fracture  of  olecranon 
process  of  ulna. 

(e)  Fracture  of  neck  or  head 
of  radius. 

(/)  Subluxation  of  head  of 
radius. 

3.  Simple  sprains  of  the  elbow. 
In    the    majority    of     cases 

swelling  occurs  so  rapidly  after  elbow  injuries  that  palpation  is  difficult. 
In  children  especially  the  administration  of  an  anesthetic  is  advisable 
in  order  to  make  a  diagnosis. 

Familiarity  with  the  surface  anatomy  of  the  elbow  region  will  be 
of  great  aid  in  an  examination  for  possible  injury.  The  more  impor- 
tant normal  landmarks  are:  (a)  The  two  condyles  of  the  humerus  and 
the  tip  of  the  olecranon  process  form  an  equilateral  triangle  when  the 
arm  is  flexed  to  a  right  angle.  When  the  arm  is  extended  they  lie  in 
a  straight  line  (Fig.  299).  (b)  The  head  of  the  radius  can  be  felt  to 
rotate  below  the  external  condyle  of  the  humerus  (Fig.  301).  (c)  An 
angle  is  formed  by  the  radius  and  ulna  with  the  humerus  when  the 


Fig.   305. — From  a   Drawing   of  an  .-v-Ray   of  a 
Fracture  of  the  Olecranon  Process. 


474 


THE   EXTKEMITIES, 


hand  and  forearm  are  held  in  a  supinated  position,  which  is  kno\^Ti 

as  the  carrying  angle. 

If  the  two  condyles  of  the  humerus  lie  in  their  normal  relation  to 

the  olecranon  process  as  determined  by  palpation,  this  will  exclude 

a  dislocation  of  both  bones  of  the  forearm,  a  fracture  of  either  condyle 

or  a  fracture  of  the  olecranon  process. 

If  the  head  of  the  radius  can  be  felt  to  rotate  in  its  normal  position 

(Fig.  301),  this  will  exclude 
a  fracture  of  the  neck  or 
head  of  the  radius  and  a 
dislocation  of  the  radius. 

The  chief  diagnostic 
points  of  the  various  in- 
juries in  the  vicinity  of  the 
elbow-joint  are  as  follows: 
I.  (a)  Supracondyloid 
Fracture  of  the  Humerus. — ■ 
I.  Deformity  may  be  pres- 
ent or  not  according  to  the 
degree  of  displacement.  If 
the  displacement  is  marked, 
there  is  a  prominence  at  the 
back  of  the  elbow  in  those 
fractures  which  follow  a  fall 
upon  the  elbow.  These  are 
called  extension  fractures 
(Fig.  303)  and  resemble  a 
dislocation  backward  of  the 
radius  and  ulna,  but  palpa- 
tion shows  the  relations  of 
the  olecranon  to  the  con- 
dyles to  be  normal  (Fig. 
299).     The    lower   end   of 

the  upper  fragment  is  often  prominent  and  easily  felt  a  little  above  the 

bend  of  the  elbow.     The  deformity  can  usually  be  readily  corrected  by 

do\\Tiward  traction. 

2.  Abnormal  mobility  and  crepitus  are  easily  elicited  by  grasping 

the  forearm   and   lower   end   of   the   humerus   and   moving  it  firmly 

forward  and  backward  while  the  shaft  of  the  humerus  is  steadied  with 

the  other  hand  or  by  an  assistant  (Fig.  302). 

I.  (b)  Intercondyloid  or  T  or  Y  Fractures  oj  Loiuer  End  of  Humerus. — 


Fig.  306. — X-RAY  OF  Fractdre  of  the  Neck  of  the  Radius 

IN  A  %'EEY  Muscular  Indi\tdual. 

The  arrow  points  to  the  point  of  separation  of  the  capitelhim 

and  shaft. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


475 


In  this  form  of  injury  an  a'-ray  is  often  necessary  in  order  to  make  an 
exact  diagnosis.  These  are  often  compound,  so  that  a  direct  inspec- 
tion is  possible.  The  signs  are  the  same  as  for  supracondyloid  frac- 
ture, but  the  relation  of  the  condyles  will  be  changed  according  to  the 
degree  of  displacement.  In  some  cases  the  condyles  are  so  widely 
separated  that  the  olecranon  passes  between  them.  Unless  the  swell- 
ing is  too  great,  the  condyles  can  be  moved  independently  of  each  other 
and  of  the  shaft.  In  some  cases  the  median  nerve  has  been  contused 
by  being  stretched  across  the 
displaced  fragments. 

I.  (c)  Epiphyseal  Separa- 
tion.— -The  signs  are  those  of 
supracondyloid  fracture,  and 
it  occurs  in  children  below  the 
age  of  ten.  It  may  involve  the 
entire  epiphysis  only  at  a  very 
early  age  (Fig.  304),  result- 
ing in  lateral  or  antero-poste- 
rior  displacement,  as  in  the 
typical  supracondyloid  form 
in  older  children  and  adults. 
The  crepitus  is  usually  muf- 
fled or  indistinct. 

A  fracture  through  the  epi- 
physis can  be  distinguished 
from  a  dislocation  of  the  el- 
bow by  the  fact  that  the 
bony  points  on  the  lower 
fragment  of  the  humerus  still 
retain  their  normal  relation  to 
the  olecranon.  It  differs  from 
the  supracondyloid  fracture 
of  older  children  and  adults 

in  showing  a  prominence,  due  to  displacement  forward  of  the  upper  frag- 
ment. This  prominence  is  found  at  a  lower  level  than  in  the  supracon- 
dyloid variety. 

One  should,  in  general,  never  make  a  diagnosis  from  an  A'-ray  of 
an  elbow-joint  injury  in  children  without  referring  frequently  to  A'-ray 
pictures  of  the  normal  joint  at  \'arious  ages.  The  presence  of  a  clear 
area  caused  by  a  normal  cartilage  may  often  lead  one  to  think  it  a  frac- 
ture line. 


I'lo.  J07. — Skial.kaph  ui'  Case  oi  Dislocation  Back- 
ward OF  Both  Bones  of  Forearm. 
U,  Ulna;  R,  radius;  c,  broken-off  coronoid  process  of 
ulna;  H,  shaft  of  humerus.  Note  in  the  shadow  the  ob- 
literation of  the  normal  depression  above  the  coronoid 
process.     (See  text.) 


476 


THE   EXTREMITIES. 


I.  {d)  Fractures  of  the  Internal  Epicondyle  or  Internal  Condyle. — 
Fractures  of  the  internal  epicondyle  are  common  in  children  on  account 
of  the  fact  that  union  with  the  shaft  does  not  occur  before  the  eight- 
eenth year.  The  fragment,  if  large,  can  be  grasped  between  the  fin- 
gers of  the  examiner  and  moved,  and  soft  crepitus  elicited. 

In  fractures  of  the  internal  condyle,  the  latter  can  be  moved  to  and 
fro  independently  of  the  shaft,  by  grasping  it  between  the  thumb  and 
index-finger.     This  abnormal  mobility  is  accompanied  by  crepitus.     One 


Fig.  308. — Forward  Dislocatiox  of  Radius,  en"  a  Boy  of  Tex. 
Compare  with  the  normal  elbow  of  same  patient  shown  in  Fig.  277.     R,  Shaft  of  radius;  U,  shaft  of  ulna; 
H,  shaft  of  humerus,     i,  Upper  epiphysis  of  radius  (capitellum);  2,  upper  epiphysis  of  ulna,  which  forms  the 
olecranon  process;  3,  lower  epiphysis  of  humerus. 


of  the  most  characteristic  signs,  if  any  displacement  of  the  fragment 
has  occurred,  is  the  fact  that  when  the-  relation  of  the  three  bony  points 
is  looked  for,  the  internal  condyle  is  found  above  the  level  of  the  exter- 
nal condyle  (Fig.  299). 

There  is  lateral  mobility  of  the  elbow-joint  present. 

1.  (e)  Fractures  of  the  External  Epicondyle  and  External  Condvle. — 
The  former  are  rare  and  so  difficult  to  recognize  that  for  practical  pur- 
poses it  is  only  necessar}'  to  consider  the  fractures  of  the  external 
condyle  itself.     The  latter  occur  more  frequently  than   those  of  the 


SPECIAL    FRACTURES    AND    DISLOCATIONS.  477 

internal  condyle,  especially  in  young  persons.  The  fragment  broken 
off  includes  the  epicondyle,  outer  portion  of  the  trochlea,  and  capi- 
tellum  (Fig.  297).  It  may  be  tilted  or  even  rotated  so  that  the  broken 
surface  looks  upward  or  outward.  The  external  condyle  is  found 
displaced  upward  when  the  three  bony  points  at  the  back  of  the  elbow 
are  palpated.  The  fragment  can  usually  be  grasped  between  the  fin- 
gers and  moved  independently  of  the  shaft,  accompanied  by  crepitus. 
In  some  cases  a  deformity  is  visible. 

II.  (a)  Fractures  0}  the  Upper  End  of  the  Ulna  and  Radius. — Frac- 
tures of  the  olecranon  process  of  the  ulna  can  be  readily  recognized 
if  there  is  a  considerable  separation  of  the  fragment  from  the  main 
portion  of  the  bone.  This  condition  is  seldom  present  in  sufficient 
degree  to  be  relied  upon  for  diagnosis.  If  it  exists  a  gap  or  depression 
can  be  felt  between  the  fragment  and  the  shaft,  and  the  former  pos- 
sesses independent  mobility. 

If  no  separation  exists  one  should  search  for  mobility  of  the  end  of 
the  olecranon  by  moving  it  laterally  and  also  holding  it  between  the 
fingers  while  an  assistant  alternately  flexes  and  extends  the  forearm. 
Voluntary  extension  of  the  elbow- joint  is  usually  absent  and  is  a  char- 
acteristic sign.  If  the  swelling  is  great  the  presence  of  an  olecranon 
fracture  should  be  suspected  from  the  inabihty  to  extend  the  arm  vol- 
untarily and  also  from  the  localized  pain. 

If  possible,  an  x-ray  should  be  taken  at  the  earhest  moment  in 
these  cases.  Fractures  of  the  coronoid  process  of  the  ulna  are  rare 
and  usually  associated  with  backward  dislocation  of  the  ulna  and 
radius.  It  renders  the  reduction  of  the  latter  easier,  but  there  is  greater 
tendency  to  recurrence.  It  probably  occurs  more  often  than  is  gener- 
ally thought,  and  must  be  searched  for  by  x-ray  examination  in  all 
severe  injuries  of  the  elbow-joint.  Dislocation  of  the  fragment  and 
resultant  excessive  callus  formation  may  greatly  interfere  with  the  func- 
tion of  the  joint. 

Fractures  of  the  Head  and  Neck  of  the  Radius. — The  recognition 
of  this  fracture  is  usually  difficult.  In  the  case  sho\\Ti  in  Fig.  306  the 
lesion  was  suspected  from  the  presence  of  great  pain  over  the  head 
of  the  radius  when  it  was  grasped  between  the  fingers,  while  the  fore- 
arm w^as  alternately  pronated  and  supinated  (Fig.  301).  In  some 
cases  the  head  will  be  found  not  to  move  when  the  shaft  is  rotated, 
and  there  may  be  crepitus.  At  the  present  time  the  use  of  the  x-ray 
has  been  found  of  the  greatest  service  in  the  diagnosis  of  such  fractures. 

Dislocations  of  the  Bones  of  the  Forearm. — Dislocation  of  both  radius 
and  ulna  backward  (Fig.  307)  or  of  the  radius  alone  forward  occurs 


478 


THE    EXTREMITIES. 


far  more  frequently  than  any  other  varieties  of  dislocation.     The  former 
injur}'  is  at  times  complicated  by  fracture  of  the  olecranon,  of  the  coro- 

noid  process,  of  the  head , 
shaft,  and  lower  end  of  the 
radius,  or  of  the  internal 
condyle  of  the  humerus. 

Dislocations  of  both 
bones  of  the  forearm  back- 
ward are  recognized  by 
careful  attention  to  the  re- 
sults of  palpation  of  the 
three  bony  points  at  the 
back  of  the  elbow.  The 
tip  of  the  olecranon  will 
be  found  either  on  a  line 
with  or  above  the  level  of 
the  two  condyles  of  the 
humerus.  The  olecranon 
also  lies  in  a  plane  which 
is  considerably  further  be- 
hind the  humerus  than  in 
the  normal  arm.  The 
head  of  the  radius  can  be 
felt,  and  often  seen,  lying 
behind  the  external  con- 
dyle of  the  humerus.  The 
lower  end  of  the  shaft  of 
the  latter  bone  can  be  felt 
as  a  projection  at  the  front 
of  the  elbow'-joint.  The 
arm  is  held  in  a  semiflexed 
position  and  there  is  great 
limitation  of  movements 
in  the  elbow-joint.  Dis- 
location of  the  radius  alone 
is  usually  of  the  forward 
variety.  It  may  at  times 
be  complicated  by  frac- 
ture of  the  upper  third  of 
the  shaft  of  the  ulna. 
Both  active  and  passive 


Fig.  309. — X-RAY  OF  Case  of  Greenstick  Fracture  of  tke 
Ulna,  Showing  the  Characteristic  Bending  of  the 
Bones  of  the  Forearm. 

The  outlines  of  the  bones  have  been  strengthened  by  tracing 
them  in  black,  and  the  light  space  in  the  ulna,  shown  at  G,  rep- 
resents the  incomplete  line  of  fracture  on  the  convex  side  of  the 
ulna.  The  skiagraph  was  taken  so  that  the  back  of  the  forearm 
is  shown.  R,  radius;  U,  ulna;  E,  lower  epiphysis  of  radius;  H, 
humerus. 


SPECIAL    FEACTURES    AND    DISLOCATIONS. 


479 


movements  of  the  elbow  are  painful   and  limited,  especially  flexion. 

Upon  examining  the  elbow  in  the 

systematic  manner  referred  to,  the 

head  of  the  radius  is  not  found  in 

its  normal  position.    Instead  of  the 

head,   one  finds  a  depression  on 

deep  palpation;  the  head  itself  is 

felt  in  front  of  the  lower  end  of  the 

humerus  on  the  radial  side  of  the 

bend  of  the  elbow. 

In  older  cases  when  the  swell- 
ing has  disappeared,  the  head  of 
the  radius  may  project  consider- 
ably above  the  level  of  the  sur- 
rounding tissues.  In  the  cases  as- 
sociated with  fracture  of  the  uLna 
the  latter  can  be  recognized  by  pal- 
pation of  the  deformity  when  the 
finger  is  passed  along  the  back  of 
the  ulna,  and  also  by  the  presence 
of  abnormal  mobility. 

Subluxation  of  the  radius,  or 
"pulled  elbow,"  occurs  in  a 
young  child  after  lifting  it  by 
the  forearm  or  pulhng  upon 
the  hand.  There  is  no  palpa- 
ble or  visible  displacement  of 
the  radius.  The  child  will  not 
use  the  arm  and  it  either  hangs 
by  its  side  or  is  supported  by  the 
other  one.  There  is  pain  on  pres- 
sure over  the  head  of  the  radius 
and  the  child  resists  any  rotary 
movements  of  the  forearm, "  es- 
pecially supination.  In  the  ma- 
jority of  cases  a  separation  can 
be  felt  between  the  lower  end 
of  the  humerus  and  the  head  of 
the  radius.  After  forced  supina- 
tion a  slight  click  is  heard  and  the  child  uses  the  arm  freely  again. 

Fractures  of  the  Shafts  of  the  Ulna  or  Radius. — Fractures  of  both 


Fig.  310. — Greenstick  Fracture  of  the  Ulna 
SHOWN  IN  Fig.  309,  after  Reduction. 
R,  Shaft  of  radius;  E,  lower  epiphysis  of  ra- 
dius; U,  shaft  of  ulna;  C,  callus  at  point  of  green- 
stick  fracture,  showing  the  relatively  large  size  of 
these  in  such  cases. 


48o 


THE   EXTREMITIES. 


bones  of  the  forearm  may  occur  simultaneously  or  either  one  alone 
may  be  broken.  In  children  the  greens  tick  or  incomplete  form  (Fig. 
308)  is  by  far  the  most  frequent  and  is  often  overlooked.  As  in  the 
case  of  the  complete  form  in  adults,  it  usually  occurs  in  the  middle 
third.  It  may  involve  one  or  both  bones.  If  after  a  fall  upon  the  fore- 
arm or  outstretched  hand  a  child  complains  of  pain  or  does  not  use 
the  arm,  a  search  for  an  incomplete  fracture  should  be  made.  The 
radius  and  ulna  can  be  palpated  in  children  throughout  almost  their 
entire  length,  so  that  a  bowing  or  angle  is  readily  detected.  The  other 
signs  are  localized  pain  and  tenderness.  An  x-tslj  examination  should 
be  made  in  every  suspected  case.  One  bone  may  be  completely  broken 
and  the  other  only  incompletely.     Complete  fractures  of  either  or  both 


Fig.  311. — Characteristic  Swelling  of  Wrist-joint  and  Deformity  in  Rf:cent  Colles'  Fractttre. 
Note  the  fullness  on  the  flexor  surface  of  wrist,  due  to  displacement  downward  of  the  upper  fragment 
of  the  radius,  and  the  more  distal  prominence  on  the  dorsal  surface  of  the  wrist,  due  to  displacement  upward  of 
the  lower  fragment  of  the  radius.  Note  also  the  swelling  and  obliteration  of  the  normal  depressions  correspond- 
ing to  the  wrist-joint. 


bones  of  the  forearm  are  not  difficult  to  recognize  unless  the  individual 
is  very  muscular  or  very  fat.  When  the  arm  is  grasped  in  the  man- 
ner shown  in  Fig.  317,  abnormal  mobility  and  crepitus  can  be  readily 
detected.  At  times  the  diagnosis  may  be  made  from  the  deformity 
alone,  which  is  either  visible  or  can  be  felt  by  palpating  the  bones. 

Injuries   in   the   Vicinity   of   the  Wrist-joint. — The  follo^\-ing 
conditions  must  be  thought  of  in  this  region: 

(a)  Fractures  of  the  lower  end  of  the  radius.     Colles'  fracture. 

(b)  Fracture  of  the  styloid  process  of  the  ulna. 

(c)  Fracture  of  both  radius  and  ulna  near  the  wrist. 

(d)  Fractures  and  dislocations  of  the  carpal  bones. 

(e)  Dislocations  of  the  wrist-joint. 
(/)  Carpo-metacarpal  dislocations. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


481 


As  in  the  case  of  injuries  of  the  shoulder-joint  and  elbow-joint, 
famiharity  with  normal  conditions  is  of  the  greatest  aid  in  making 
a  diagnosis.  The  injured  wrist  should  always  be  compared  wdth  the 
opposite  sound  one.     One  should  first  observe  the  presence  of  deformity, 


Fig  312. — Outlines  of  w-rav  Pictures  of  Various  Forms  of  Fracture  of  the  Lower  End  of  the  Radius. 
I,  Through  base  of  styloid  process  ;  2,  through  inner  angle  of  lower  end  of  radius  ;  3,  transverse  fracture 
without  displacement  ;  4,  comminution  of  distal  fragments  ;  5,  separation  of  epiphysis  ;  6  and  7,  separation  of 
epiphysis  with  chips  of  diaphysis  ;  8,  impaction  of  lower  into  upper  fragments  ;  9,  typical  Colles'  (lateral  view)  ; 
10,  reverse  Colles'. 


which  is  often  quite  marked  (Fig.  311).  The  injured  hand  is  then 
grasped  by  the  hand  of  the  examiner  while  upward  and  downward 
movements  are  imparted  to  the  lower  end  of  the  radius  and  ulna  to 
determine  abnormal  mobility  and  crepitus.  A  second  and  very  use- 
31 


482 


THE    EXTREMITIES. 


ful  method  is  to  grasp  the  lower  end  of  the  forearm  with  the  two  hands 
of  the  examiner  as  shown  in  Fig.  317.  In  many  of  the  injuries,  especi- 
ally of  the  carpal  bones,  an  .T-ray  picture  will  be  found  to  be  indispen- 
sable. 

(a)  Fractures  of  the  Lower  End  of  the  Radius.  Colles''  Fracture. — 
Our  knowledge  of  this  most  common  form  of  fracture  has  been  greatly 
increased  through  the  use  of  the  .v-rays.     The  various  forms  of  fracture 

are  shown  in  Fig.  312. 
Many  of  these  are  associ- 
ated with  no  deformity 
and  show  the  necessity 
of  routine  skiagraphic  ex- 
aminations, not  only  for 
the  purpose  of  diagnosis, 
but  for  that  of  treatment 
as  well.  The  classes 
which  cause  sufficient  de- 
formity to  be  recognized 
without  the  use  of  the 
.Y-ray  are  the  commin- 
uted and  the  impacted 
forms  and  those  spoken 
of  as  typical  Colles'  frac- 
tures. In  the  latter,  the 
line  of  fracture  is  more 
or  less  transverse  and 
there  is  accompanying 
displacement  of  the  lower 
fragment  either  to  the 
radial  side  or  posteriorly 
or  both.  In  epiphyseal 
separation  there  is  usu- 
■  ally  less  deformity  than 
in  the  typical  form.  The  most  marked  symptoms  of  a  Colles'  fracture  are 
the  prominence  over  the  back  of  the  wrist  and  the  change  in  outhne  of  the 
ulnar  side  of  the  wrist  (Fig.  313).  The  former  is  due  to  the  upward 
displacement  of  the  lower  fragment  and  the  latter  to  the  displacement 
of  the  lower  fragment  with  the  hand  toward  the  radial  side  of  the  fore- 
arm. Crepitus  and  abnormal  mobility  can  often  be  obtained  by  grasp- 
ing the  wrist  in  one  of  the  ways  described  above. 

If  great  swelling  exists  or  there  is  little  displacement,  and  also  in 


Fig.  313. — Deformity  Following  Fracture  at  the  Lower  End 
OF  THE  Radius. 
This  is  the  exterior  of  the  same  case  as  is  shown  in  x-T3.y  of 
Fig.  315.  Note  the  displacement  of  the  hand  and  lower  end  of  the 
radius  toward  the  radial  side  of  the  arm,  causing  the  styloid  pro- 
cess of  the  ulna  to  become  abnormally  prominent. 


SPECIAL    FRACTURES    AND    DISLOCATIONS.  483 

children,  such  an  injury  must  be  suspected  if  there  is  inability  to  use 
the  wrist  and  well-localized  pain  referred  on  pressure  to  the  lower  end 
of  the  radius. 

(b)  and  (c)  Fractures  of  the  styloid  process  of  the  ulna  alone  and 
of  both  bones  near  the  wrist  are  quite  uncommon.  The  former  can 
be  recognized  by  the  abnormal  mobility  of  the  styloid  process.  In 
fractures  of  both  bones  the  diagnosis  is  made  from  the  presence  of  abnor- 
mal mobility,  and  crepitus  at  the  lower  ends  of  both  bones. 

(d)  Fractures  and  Dislocations  oj  the  Carpal  Bones. — The  recogni- 
tion of  these  injuries  is  of  great  importance,  since  many  cases  of  sprains 
or  contusions  of  the  wrist  are  in  reality  fractures  or  dislocations  of  the 
carpal  bones.  The  large  majority  of  these  are  either  simple  fractures 
of  the  scaphoid  or  anterior  dislocations  of  the  semilunar  bone.  The 
two  injuries  are  frequently  combined,  and  in  such  cases  (Codman  and 


Fig.  314. — View  from  Radial  Side  of  a  Typical  Silver-fork  Deformity  Following  Colles  Fracture. 

(See   text.) 

Chase^)  the  proximal  fragment  of  the  scaphoid  is  usually  dislocated 
forward  with  the  semilunar  bone.  Simple  fracture  of  the  scaphoid 
gives  a  definite  clinical  picture,  and  may  be  recognized,  even  without 
the  x-ray,  by  the  association  of  the  following  symptoms:  viz.,  {a) 
The  history  of  a  fall  on  the  extended  hand;  (b)  locaHzed  swelling  in 
the  radial  half  of  the  wrist-joint;  (c)  acute  tenderness  in  the  "anatomic 
snuff-box"  when  the  hand  is  adducted;  {d)  limitation  of  extension 
by  muscular  spasm,  the  overcoming  of  which  causes  unbearable 
pain. 

Anterior  dislocation  of  the  semilunar  bone  should  be  recognized 
clinically,  even  without  the  :x;-ray,  by  the  association  of  the  following 
symptoms:  viz.,  (a)  The  history  of  an  injury  of  considerable  violence 
to  the  extended  or  twisted  wrist;  {b)  a  silver- fork  deformity,  the  poste- 
rior prominence  of  which  corresponds  with  the  head  of  the  os  magnum, 

■  ^  "Annals  of  Surgery,"  May,  1905. 


484  THE    EXTREMITIES. 

and  between  which  and  the  lower  end  of  the  radius  is  found  a  groove 
representing  the  position  formerly  occupied  by  the  now  anteriorly 
dislocated  semilunar;  (c)  a  tumor  under  the  flexor  tendons  of  the  wrist 
just  anterior  to  the  lower  end  of  the  radius;  (d)  a  shortened  appearance 
of  the  palm  as  compared  with  the  other  hand;    (e)  stiffness  of  the  parti- 


FlG.    315. — X-RAY   OF    A    COLLES'    FrACTDRE,    WITH    MARKED     DISPLACEMENT     OF    THE     LOWER     FRAGMENT 

Toward  the  Radl\l  Side  of  the  Arm. 
This  is  the  same  case  shown  in  Fig.  313.     Xote  how  the  radius  has  been  shortened  by  the  displace- 
ment of  the  lower  fragment,  so  that  the  styloid  process  of  the  ulna  projects  quite  prominently  to  the  inner 

side  of  the  wrist. 

ally  flexed  fingers,  motion  of  which,  either  acti\-e  or  passive,  is  painful; 
(/)  the  persistence  of  the  normal  relation  of  the  styloid  processes  of  the 
ulna  and  radius  and  the  existence  of  shortening  of  the  distance  from 
the  radial  styloid  to  the  base  of  the  first  metacarpal. 

(e)  and  (/;  Dislocations  oj  the  Wrist  and  Carpo-metacarpal  Disloca- 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


485 


tions. — Dislocation  of  the  wrist  is  usually  compound,  but  is  uncommon. 
It  may  occur  in  a  backward  or  forward  direction.  The  former  resembles 
a  Colles'  fracture,  but  dii^ers  from  it  by  the  fact  that  the  prominence 
on  the  front  of  the  wrist  extends  further  down,  evea  to  the  thumb,  and 
ends  more  abruptly  in  dislocation  than  in  fracture.  The  dorsal  promi- 
nence is  also  more  sharply  outlined  at  its  upper  border  in  a  fracture. 
In  the  forward  variety  there  is  a  marked  depression  on  the  back  of  the 


Fig.  316. — Method  of  Examination  for  Fractures  of  the  Lower  End  of  the  Radius. 
In  the  examination  of  the  left  forearm  the  wrist  is  grasped  by  the  left  hand  of  the  examiner  close  to  the 
point  of  fracture,  while  the  right  arm  grasps  the  bone  just  above  the  suspected  point  of  fracture.     In  the  ex- 
amination of  the  right  arm  this  order  should  be  reversed. 


wrist,  at  the  upper  border  of  which  is  seen  the  sharp  outline  of  the 
lower  ends  of  the  radius  and  uhia.  There  is  a  rounded  prominence 
on  the  front  of  the  wrist  formed  by  the  displaced  carpus.  The  hand 
appears  to  be  shortened  at  the  expense  of  the  wrist. 

Dislocation  backward  of  the  metacarpal  bone  of  the  thumb  is  the 
most  frequent  and  is  oftenest  incomplete.  The  posterior  edge  of  the 
base  of  the  metacarpal  bone  can  be  seen  and  felt  in  the  depression  known 
on  the  back  of  the  thumb  between  the  two  long  extensors.  In  the 
complete  form  this  dorsal  prominence  is  more  marked.  Dislocations 
of  the  other  metacarpal  bones  alone  or  of  all  five  simultaneously  are 


486 


THE   EXTREMITIES. 


quite  rare,  and  the  reader  is  referred  to  the  special  text-books  on  frac- 
tures for  their  recognition. 

Injuries  of  the  Metacarpal  Bones  and  Phalanges. — Fractures 
of  the  metacarpal  bones  and  phalanges  are  far  more  common  than 
was  thought  to  be  the  case  before  the  use  of  the  x-ray.  Many  are 
not  diagnosed,  owing  to  the  absence  of  displacement,  unless  a  skia- 
graph is  taken  of  every  severe  sprain  or  contusion  of  the  hand.  The 
deformity  in  metacarpal  fracture  is  usually  quite  shght,  except  in  those 
close  to  the  metacarpo-phalangeal  joint.     In  the  latter  class  there  is 


Fig.  317. — One  of  the  Methods  of  Examination  for  Fracture  of  the  Lower  End  of  the  Radius. 
In  the  case  of  the  right  radius,  the  patient's  hand  is  grasped  by  the  right  hand  of  the  examiner  as  though 
shaking  hands.     The  index-finger  of  the  examiner's  right  hand  is  placed  below  the  lower  end  of  the  radius,  while 
the  fingers  of  the  examiner's  other  hand  are  placed  on  the  dorsal  side  of  the  same  bone      By  a  rocking  or  to-and- 
fro  motion  a  false  point  of  motion  can  be  readily  detected. 


often  a  distinct  depression,  best  seen  when  the  joint  is  flexed,  resem- 
bhng  a  dislocation  at  this  joint.  At  times  the  displacement  of  frag- 
ments in  the  shaft  can  readily  be  palpated.  The  deformity  is  often 
obscured  by  the  great  amount  of  swelhng.  Abnormal  mobility  and 
crepitus  can  be  elicited  by  alternately  flexing  and  extending  the  iingers, 
while  the  suspected  bone  is  grasped  between  the  index-fingers  and 
thumbs  of  both  hands  of  the  examiner,  the  latter  being  placed  on  the 
dorsum  and  volar  surfaces  of  the  hand. 

Fractures   of   the   phalanges   are   usually   due   to   crushing  forces. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


487 


The  proximal  phalanx  is  most  frequently  involved.  The  diagnosis 
can  be  readily  made  by  inspection  of  the  wound  in  compound  fractures. 
In  the  simple  variety  crepitus  and  abnormal  mobility  are  easily  elicited 
by  grasping  the  phalanx  with  the  fingers  of  the  examiner  and  moving 
it  to  and  fro.     In  those  close  to  a  joint  the  diagnosis  is  more  difficult, 


Fig.   318. — X-RAY   OF   A   Normal   Hand   and   Wrist-joint. 
The  radius  and  ulna  have  been  outlined  in  white;   the  carpal  bones  in  black.     U,  Ulna;   R,  radius;   P, 
pisiform;   CF,  cuneiform;   SL,  semilunar;   SP,  scaphoid;   TM,  trapezium;  T,  trapezoid;  OM,  os  magnum; 

U,  unciform. 


and  often  necessitates  the  use  of  the  rv-ray,  especially  in  children,  in 
whom  epiphyseal  separation  (Fig.  319)  is  not  infrequent. 

Dislocations  of  the  proximal  phalanx  of  the  thumb  are  the  most 
frequent  of  all,  in  the  hand.  The  backward  form  is  the  most  common 
one.     The  proximal  end  of  the  phalanx  is  to  be  seen  and  felt  on  the 


488 


THE   EXTREMITIES. 


back  of  the  thumb,  lying  upon  the  metacarpal  bone,  the  thumb  being 
adducted.  The  head  of  the  metacarpal  bone  can  be  seen  and  felt 
projecting  on  the  front  of  the  thumb.  In  forward  dislocations  the 
deformity  is  the  opposite  of  the  above. 

Dislocations  at  the  metacarpo-phalangeal  joints  occur  most  fre- 
quently in  the  thumb  and  index-finger  and  in  a  backward  direction. 
There  is  a  prominence  on  the  back  of  the  hand,  due  to  the  base  of  the 

phalanx,  and  one  in  the  palm, 
due  to  the  head  of  the  displaced 
metacarpal  bone.  The  finger 
may  be  extended  or  slightly 
flexed.  The  forward  form  is 
less  frequent  and  the  deformity 
is  the  reverse  of  that  of  the 
backward  variety. 

Dislocations  of  the  mid- 
dle and  distal  phalanges  usu- 
ally occur  in  a  backward 
direction  and  are  not  difficult 
to  recognize  from  the  deform- 
ity. They  are  frequently  com- 
pound. 

Fractures  of  the  Pelvis. — 
Fractures  of  the  pelvis  may  be 
[  divided  into : 

I.  Those  which  involve  the 
pelvic  girdle  as  a  whole: 

ia)  Separation  of  the  sym- 
physis pubis. 

{h)  Fracture  of  the  horizon- 

FiG.  319. — Fracture  of  Metacarpal  Bone  of  Little     i^tal   and   aSCenClmg   rami    Ot    tJie 

^^^^'^^  pubes. 

(c)  Vertical  (single  or  double)  fractures  of  the  lateral  portions,  e.  g., 
the  ilium  passing  through  the  acetabulum. 
2.  Those  which  involve  individual  bones: 

(a)  Fractures  of  the  expanded  upper  portion  of  the  ihum. 

(b)  Fractures  of  the  rim  of  the  acetabulum. 

(c)  Fractures  of  the  ischium,  sacrum  and  coccyx. 

Of  the  above,  the  commonest  are  those  in  which  the  rami  of  the  pubis 
or  ischium  or  the  alae  of  the  ilium  are  broken.  The  remaining  ones  are 
very  rare.     Fractures  of  the  rim  of  the  acetabulum  resemble  dislocation 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


489 


of  the  hip  so  closely  that  they  will  be  considered  under  the  injuries 
of  the  hip.  For  diagnostic  purposes  fractures  of  the  pelvis  are  best 
divided  into  (a)  those  complicated  hy  visceral  injury,  and  (h)  those 
not  accompanied  hy  such  a  lesion.  The  possibility  of  a  fracture  of 
the  pelvis  with  or  without  visceral  complications  must  always  be 
thought  of  in  examining  a  patient  who  has  been  subjected  to  a  crush- 
ing force,  such  as  being  run  over,  caught  between  buffers,  etc.  The 
diagnosis  of  fractures  of  the  crest  of  the  ilium  and  of  those  involv- 
ing the  ala  or  expanded  upper  portion  of  the  ilium  is,  as  a  rule,  not 
difficult.     Crepitus  is  seldom  present  and  but  little  force  should  be 


Fig.  320. — Antero-posterior  and  Lateral  «-ray  View  of  Fracture   of  the  Shaft   of  the   Second 

Phalanx  of  the  Middle  Finger,  in  a  Girl  of  Eight. 

Exterior  picture  of  this  is  shown  in  Fig.  321. 


employed  in  efforts  to  elicit  it.  Chief  reliance  must  he  placed  upon 
localized  pain  and  abnormal  mohility.  These  are  best  elicited  by 
a  systematic  examination  of  the  entire  crest  of  the  ilium,  placing  a 
hand  on  each  side  of  the  pelvis,  while  pressure  is  gently  exerted  upon 
the  underlying  bone.  In  many  cases  it  is  possible  by  this  manipula- 
tion to  detect  either  displaced  fragments  or  abnormal  mobihty.  The 
latter  sign  is  more  apt  to  be  present  than  the  former.  Repeated  exam- 
inations will  often  show  the  pain  to  be  accurately  locahzed  to  the  seat 
of  fracture.  In  fractures  of  other  portions  of  the  pelvis  it  is  inadvis- 
able to  attempt  to  make  a  diagnosis  by  manipulation.     Usually  there 


490  THE   EXTREMITIES. 

is  but  little  displacement,  so  that  the  diagnosis  must  be  made  from  the 
accompanying  visceral  injuries.  A  rectal  examination  and  an  :v-ray 
should  never  be  omitted  in  doubtful  cases,  as  they  often  enable  an 
exact  diagnosis  to  be  made. 

The  complications  of  fractures  of  the  pelvis  are,  in  the  order  of 
their  frequency:  (i)  Rupture  of  the  urethra;  (2)  rupture  of  the  bladder; 
(3)  rupture  of  one  of  the  other  abdominal  viscera  (kidney,  spleen,  Kver, 
bowel,  etc.);    (4)  rupture  of  the  external  ihac  artery  or  vein. 

A  diagnosis  of  such  visceral  injuries  is  only  of  value  for  treatment 
by  operation  if  made  during  the  first  twelve  to  twenty-four  hours  after 


Fig.  321. — Compound  Fracture  of  Phalanges. 
This  is  the  exterior  view  of  the  case  of  which  the  ^-ray  is  shown  in  Fig.  320.     (See  text.) 

injury,  and  if  the  patients  are  unable  to  urinate  or  blood  escapes  from 
the  urethra  they  should  be  most  thoroughly  examined  with  these  lesions 
in  mind. 

The  principal  diagnostic  points  of  these  are  as  follows: 
I.  Rupture  of  the  Urethra. — (a)  Retention  of  urine.  If  the  patient 
is  able  to  urinate,  the  act  .is  only  accomplished  with  great  difficulty 
and  paki,  the  urine  is  scanty  and  accompanied  by  considerable  amounts 
of  clotted  and  hquid,  bright-colored  blood,  (b)  Pain  over  the  peri- 
neum and  end  of  the  penis,  (c)  Swelling  and  evidences  of  subcuta- 
neous hemorrhage  of  the  perineum,  scrotum,  and  penis,  (d)  Blood 
escapes  from  the  urethra,  and  when  the  catheter  is  inserted  bloody 
urine  in  small  c|uantity  is  withdrawn. 


SPECIAL    FRACTURES    AND   DISLOCATIONS. 


491 


2.  Rupture  of  the  Bladder. — In  extraperitoneal  rupture,  an  area 
of  dullness  appears  (Fig.  323)  above  the  pubes  and  there  is  a  feeling  of 
fullness  around  the  bladder  when  a  rectal  examination  is  made.  There 
is  retention  of  urine  or  an  incontinence  of  retention  exists.  Small 
amounts  of  bloody  urine  constantly  escape  from  the  external  meatus. 
If  a  catheter  is  inserted  into  the  bladder,  a  small  quantity  of  bloody 
urine  is  obtained.  If,  as  in  one  case  of  the  author's,  a  fracture  of  the 
pelvis  is  comphcated  both  by  an  extraperitoneal  rupture  of  the  blad- 


FiG.  322. — Typical  Locations  of  Lines  of  Fracture  in  Fractures  of  the  Pelvis. 
Note  the  line  of  fracture  passing  through  the  horizontal  ramus  of  the  pubis,  and  a  second  at  the  junc- 
tion of  the  descending  ramus  of  the  pubis  and  ascending  ramus  of  the  ischium.     The  posterior  fracture  lines 
pass  through  the  ilium  in  a  Y  manner,  terminating  in  the  greater  sciatic  notch. 


der  and  a  rupture  of  the  urethra,  a  diagnosis  of  the  presence  of  both 
conditions  is  seldom  possible.  In  the  majority  of  cases  the  bladder 
injury  which  accompanies  fractures  of  the  pelvis  is  in  the  form  of  an 
extraperitoneal  rupture.  Those  in  which  the  tear  is  in  that  portion 
of  the  viscus  covered  by  peritoneum  are  much  less  fre(j[uent.  The 
diagnosis  of  such  intraperitoneal  ruptures  of  the  bladder  has  already 
been  referred  to.  The  symptoms  are  those  of  a  septic  peritonitis,  but 
are  slower  and  more  insidious  in  their  appearance  than  in  the  case  of 


492 


THE    EXTREMITIES. 


a  ruptured  intestine,  etc.  Injuries  of  the  other  abdominal  viscera 
must  always  be  thought  of  in  connection  with  fractures  of  the  pelvis. 
Their  symptoms  and  diagnosis  do  not  differ  from  those  previously 
given. 

The  Diagnosis  of  Injuries  of  the  Hip. — The  possibihty  of  the 
following  lesions  must  be  borne  in  mind  in  adults: 

1.  Fracture  of  the  neck  of  the  femur. 

2.  Dislocation  of  the  hip. 

3.  Fracture  of  the  head  of  the  femur  or  rim  of  the  acetabulum. 

4.  Fracture  of  and  through  the  trochanter. 

5.  Contusion  of  the  hip. 


Fig.  323. — Varieties  of  Fractures  of  the  Pelvis  and  Most  Frequent  Coupuications. 
I,  Shows  the  most  frequent  lines  of  fracture  of  the  pelvis  (see  text);  2,  shows  the  three  most  frequent 
complications  of  fractures  of  the  pelvis.  RU,  Rupture  of  urethra  associated  with  extravasation  of  urine  into 
the  scrotum  (5)  and  penis  {p)\  B,  bladder.  The  arrow  upon  the  anterior  wall  indicates  an  extraperitoneal 
rupt\ire  of  the  bladder  with  extravasation  of  urine  into  the  extraperitoneal  cellular  tissue  around  the  bladder 
and  between  the  peritoneum  and  anterior  abdominal  wall  (EPS).  The  arrow  situated  upon  the  posterior  wall 
and  the  fundus  of  the  bladder  indicates  the  escape  of  urine  through  an  intraperitoneal  tear  into  the  free  peritoneal 
cavity.  The  black  area  (UE)  indicates  the  urine  escaping  between  the  coils  of  intestine  into  the  general  peri- 
toneal cavity  (PC). 


In  children  and  young  adults  the  possibility  of  an  epiphyseal  sepa- 
ration or  traumatic  coxa  vara  must  also  be  thought  of.  The  exami- 
nation when  conducted  in  a  systematic  manner  will  enable  a  diagnosis 
to  be  made  in  the  majority  of  cases  without  the  use  of  an  x-ray.  The 
latter  should,  however,  be  employed  whenever  possible.  Satisfactory 
skiagraphs  of  the  hip,  especially  in  adults,  are  very  difficult  to  obtain 
unless  the  operator  has  had  considerable  experience  and  is  provided 
with  an  excellent  tube. 

The  chief  points  to  be  determined  are:    (a)  The  attitude  of  the 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


493 


limb;  (b)  the  amount  of  shortening  as  determined  by  a  measurement 
of  the  hmb  in  the  manner  indicated  in  Fig.  324,  viz.,  from  the  lower 
border  of  the  inner  malleolus  (when  the  limb  is  adducted)  through 
the  middle  of  the  patella  to  the  anterior  superior  spine  of  the  ihum; 
(c)  the  relation  of  the  upper  border  of  the  trochanter  to  the  Roser- 
Nelaton  hne  (Fig.  325);    (d)  gentle  manipulation  of  the  limb  to  deter- 


r 


Fig.  324. — Measurement  of  Length  oe  Limb  to  be  Employed  in  Cases  of  Dislocation  of  the  Head  of 
THE  Femur  or  Fracture  of  its  Neck. 
One  end  of  the  steel  tape-measure  is  laid  upon  the  anterior  superior  spine  of  the  ilium,  which  has  been  pre- 
viously outlined  with  ink  or  a  blue  pencil,  while  the  other  hand  holds  the  tape-measure  immediately  below  the 
inner  malleolus.  The  tape  passes  through  the  middle  of  the  patella.  Both  limbs  should  be  placed  flat  upon  the 
table  at  an  equal  distance  from  the  median  line,  i.  e.,  adducted. 


mine  the  presence  or  absence  of  crepitus,  abnormal  mobility,  or  fixa- 
tion, etc. 

In  doubtful  cases  it  is  advisable  to  administer  an  anesthetic,  owing 
to  the  fact  that  the  muscular  rigidity  disappears;  otherwise  it  might 
render  a  diagnosis  very  difficult  or  impossible. 

The  principal  diagnostic  features  of  the  above  named  lesions  of 
the  hip  are: 

I.  Fractures  0}  the  Neck  0}  the  Femur. — These  may  take  place 
either  at  the  point  of  junction  of  the  neck  or  at  the  base  of  the  neck 


494 


THE    EXTREMITIES. 


where  it  joins  the  shaft.  It  is  of  httle  importance,  from  the  stand- 
point of  either  diagnosis  or  treatment,  to  determine  whether  the  frac- 
ture is  situated  within  or  without  the  capsule,  i.  e.,  intracapsular  or 
extracapsular. 

It  is  of  far  more  value  to  ascertain  whether  the  fracture  is  impacted 
or  not.  Loss  of  function  of  the  hmb  is,  as  a  rule,  quite  marked. 
The  patient  is  unable  to  walk  upon  the  hmb  or  to  move  it  without  ex- 
periencing great  pain  in  the  hip,  and  then  only  to  a  very  limited  extent. 
There  is  often  pain  on  pressure  over  the  trochanter  or  neck  of  the  bone. 
The  position  is  quite  characteristic  (Fig.  326).     The  hmb  is  usually 


Fig.  325. — Method  of  Determining  the  Relation  of  the  Trochanter  to  the  Roser-Nelaton  Line. 
The  patient  is  laid  upon  the  side  of  the  body  opposite  to  the  one  to  be  examined,  the  steel  tape  is  stretched 
from  the  anterior  superior  spine  of  the  ilium,  ASSP,  to  the  tuberosity  of  the  ischium.  These  two  points  are 
fixed  by  the  index-fingers  of  the  two  hands,  preferably  those  of  an  assistant,  while  the  examiner  marks  the  lower 
level  of  the  tape  as  it  crosses  the  upper  border  of  the  trochanter.  Under  normal  conditions  the  tape  should  pass 
exactly  along  the  upper  border  of  the  trochanter. 


everted  so  that  the  outer  border  of  the  foot  rests  upon  the  bed.  Quite 
rarely  the  hmb  is  inverted,  this  being  more  marked  after  a  few  days. 
Measurement  of  the  limb  must  always  be  carried  out  with  both  Hmbs  in 
the  same  position,  if  possible  brought  as  near  as  may  be  to  the  median 
Hne  of  the  body  with  the  toes  pointing  upward.  The  two  standard 
modes  of  measurement  are:  (a)  From  the  lower  border  of  the  inner 
malleolus  to  the  anterior  superior  spine  of  the  ihum  (Fig.  324). 
(b)  Bryant's  method.  A  hne  is  dropped  from  the  anterior  superior 
spine  to  the  table  or  bed  in  a  perpendicular  manner.  The  distance 
from  the  upper  border  of  the  trochanter  to  this  hne  (Fig.  325)  is  less 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


495 


on  the  side  of  the  injury  than  upon  the  opposite  side.  Both  of  these 
measurements  should  always  be  made  upon  the  bare  skin,  the  various 
points  having  been  previously  marked. 

In  fracture  of  the  neck  of  the  femur  the  above  measurements  will 
show  a  shortening  which  varies  from  a  small  fraction  of  an  inch  to  two 
or  three  inches.     It  may  be  present  at  its  maximum,  just  after  the  acci- 


FlG.  326. E VERSION  OF  LoWER  EXTREMITY  IN  A  CaSE  OF  RECENT  FRACTURE  OF  THE  NeCK  OF  THE  FeMDR. 

The  arrow  points  to  the  markedly  everted  limb,  i  and  2,  Anterior  superior  spines  of  the  ilium;  3  and 
4,  placed  on  center  of  patellae;  note  how  the  patella  on  the  fractured  side  points  outward;  5  and  6,  marks 
placed  on  lower  border  of  internal  malleoli.  The  measurement  of  the  limb  for  shortening  should  be  made  as 
shown  in  Fig.  324,  from  2  to  6  on  the  fractured  side,  and  i  to  5  on  the  normal  side,  passing  through  the  middle 
of  the  patellae.  The  characteristic  shortening  of  the  limb  can  be  observed  by  comparing  the  points  5  and  6, 
taking  into  consideration  at  the  same  time  the  elevation  of  the  pelvis  on  the  side  of  the  injury. 


dent,  or  absent  at  first  and  appear  gradually  or  suddenly  after  a  few 
hours  to  days.  It  must  not  be  forgotten  that  a  normal  difference  of 
4  to  I  inch  may  exist  in  the  length  of  the  hmbs.  Crepitus  is  present 
in  unimpacted  but  is  absent  in  impacted  fractures. 

Only  the  most  gentle  manipulation  is  permissible  to  elicit  crepitus, 
since  rough  handling  may  readily  do  great  damage  in  breaking  up  an 
impaction. 


496 


THE    EXTREMITIES. 


Palpation  of  the  neck  of  the  femur  in  the  manner  shown  in  Fig. 
328,  while  an  assistant  rotates  the  limb  ver}^  gently,  will  often  enable 
one  to  detect  abnormal  mobility,  thickening  or  tenderness  about 
the  neck  of  the  bone.  The  histor}^  of  the  case  will  show  that  the 
majority  of  patients  fell  upon  the  region  of  the  greater  trochanter, 
rarely  upon  the  more  distant  portions  of  the  limb.  Fracture  of  the 
neck  of  the  femur  in  young  people  is  considered  separately. 

2.  Dislocation  of  the  Hip. — This  may  occur  chiefly  in  a  forward 
or  backward  direction.  Of  the  posterior  or  backward  variety  there 
are  two  forms:    (a)  the  iliac,  the  head  resting  upon  the  dorsum  of  the 


Fig.  327. — X-RAY  or  a  Fracture  of  the  Neck  of  the  Femur,  at  the  Junction  of  the  Head  and  Neck 

WITH  Upward  Displacement  of  the  Shaft  of  the  Femur. 
On  the  opposite  side  note  the  outlines  of  the  normal  femur  and  hip- joint.     This  a;-ray  was  kindly  loaned  to  the 

author  by  Dr.  Le  Moyne  Wills. 


ilium,  and  {h)  the  ischiadic,  the  head  being  located  in  the  sciatic  notch. 
Of  the  anterior  or  forward  variety  there  are  also  two  forms:  (a)  the 
obturator  or  thyroid,  the  head  lying  over  the  obturator  foramen,  and 
{h)  the  pubic,  the  head  resting  upon  the  pubic  ramus. 

The  majority  of  hip  dislocations  are  dorsal  (55  per  cent.),  the  next 
most  frequent  are  the  sciatic  (20  to  25  per  cent.),  then  the  obturator 
(15  per  cent.),  and  the  pubic  (5  per  cent.). 

The  signs  of  the  two  forms  of  backward  dislocation  are  practically 
the  same,  those  of  the  dorsal  being  more  marked  than  is  the  case  with 
the  sciatic  variety.  The  position  of  the  limb  is  one  of  moderate  adduc- 
tion and  flexion,  marked  inversion,  and  more  or  less  shortening,  the 


SPECIAL    FRACTURES    AND   DISLOCATIONS. 


497 


toes  of  the  injured  limb  resting  upon  the  sound  foot  (Fig.  329).  Meas- 
urement of  the  Hmb  shows  that  the  trochanter  hes  above  the  Roser- 
Nelaton  hne.  It  is  almost  impossible  to  bring  the  two  limbs  into  a 
sufficiently  symmetrical  position  to  enable  an  accurate  measurement 
of  their  length  to  be  made,  but  this  is  rarely  necessary  to  make  a  diag- 
nosis. 

The  head  of  the  bone  can  be  indistinctly  felt  through  the  gluteal 
muscles,  especially  when  attempts  are  made  to  rotate  the  limb. 

In  forward  or  anterior  dislocations  of  the  hip  the  limb  is  shghtly 


Fig.  328. — Method  of  Examination  of  the  Lower  Extremity  for  Abnormal  Motion  at  Neck  of  Femdr. 
For  photographic  purposes  it  was  necessary  to  have  the  examiner  stand  upon  the  left  side  of  the  patient. 
In  practice  in  examining  the  right  lower  extremity  the  left  hand  should  grasp  the  trochanter,  the  fingers  placed 
upon  the  back  of  the  latter,  and  the  thumb  upon  its  anterior  surface.  The  right  hand  should  be  placed  across 
the  front  of  the  ankle-joint.  In  examining  the  left  Kmb,  the  order  should  be  reversed,  the  right  hand  being 
placed  over  tjie  trochanter,  and  the  left  over  the  ankle. 


flexed,  abducted,  and  rotated  outward.  There  is  apparent  lengthen- 
ing of  the  limb,  but  careful  measurement  will  show  that  this  is  not  real. 

In  the  obturator  form,  the  head  of  the  bone  can  be  indistinctly  felt 
toward  the  obturator  foramen.  In  the  pubic  form  the  hmb  is  consider- 
ably more  abducted  and  everted  than  in  the  thyroid  variety.  The 
head  of  the  femur  can  also  be  more  distinctly  felt  in  the  groin. 

3.  Fracture  of  the  Head  of  the  Femur  or  Rim  of  the  Acetabulum. — 
The  former  is  so  rare  and  has  so  few  characteristic  signs  that  it  may 
be  left  out  of  consideration  in  the  differentiation  of  injuries  of  the  hip. 

Fractures  of  the  acetabulum  are  also  infrequent.  In  the  majority 
of  such  cases  the  posterior  rim  of  the  acetabulum  is  broken  off  and  the 
32 


498 


THE    EXTREMITIES. 


accompanying  dislocation  is  backward.  Fracture  of  the  rim  of  the 
acetabulum  may  occur  as  a  complication  of  backward  dislocations  of 
the  hip,  from  which  it  can  only  be  distinguished,  without  the  use  of  the 
rv-ray,  by  the  fact  that  the  dislocation  can  be  reduced  -without  difficulty, 
possibly  with  crepitus,  but  tends  to  recur. 

It  can  be  distinguished  from  fracture  of  the  neck  of  the  femur  by 
the  straightness  and  lack  of  eversion  of  the  Hmb,  and  from  backward  dis- 
location of  the  hip,  by  the  position  of  the 
hmb,  viz.,  adduction,  inward  rotation,  and 
slight  flexion. 

4.  Fracture  of  or  through  the  great  tro- 
chanter. Both  of  these  are  very  rare.  In 
the  former  the  diagnosis  can  only  be  made 
without  a  skiagraph  by  the  independent 
mobihty  of  the  trochanter.  In  the  frac- 
ture through  the  great  trochanter,  the  per- 
trochanteric fracture  of  KocJier,  the  differ- 
entiation from  ordinary  fractures  of  the 
neck  is  impossible  unless  a  prominent 
angle  is  distinctly  visible  anteriorly,  which 
is  formed  by  the  two  fragments.  The 
eversion  and  shortening  of  the  limb  are 
the  same  as  in  fracture  of  the  neck. 

5.  Contusion  of  the  Hip. — If  the  case 
has  been  systematically  examined  as  to 
the  history  of  the  accident,  the  posture  and 
loss  of  function  of  the  limb,  the  shortening 
and  fLxation,  the  diagnosis  from  a  simple 
contusion  ought  not  to  present  any  diffi- 
culties. Contusion  of  the  hip  may  occur 
at  any  age.     It  usually  follows  a  fall  upon 

the  trochanter,  and  there  are  often  evidences  of  a  contusion  of  the  soft 
parts  around  it.  The  hmb  is  straight,  the- head  of  the  bone  cannot 
be  felt  in  an  abnormal  place,  there  is  no  shortening,  and  the  trochanter 
hes  in  the  Roser-Nelaton  hne  and  rotates  in  the  normal  manner.  There 
may  be  localized  pain  and  some  limitation  of  motion.  If  there  is  any 
doubt  the  administration  of  an  anesthetic  is  of  great  aid.  The  same 
may  be  said  for  the  x-ray. 

Injuries  of  the  Hip  in  Children. — Acquired  traumatic  dislocations 
of  the  hip  are  infrequent  in  early  hfe,  and  until  recent  years  it  was 
thought  that  fractures  of  the  neck  of  the  femur  were  equally  rare. 


Fig.  329. — Dislocation  of  Hip,  Dor- 
sum Ilii  Variety  (Macdonald). 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


499 


Coxa  Vara  Traumatica. — This  name  was  first  given  by  Sprengel  ^ 
in  1898  to  a  condition  following  injuries  of  the  neck  of  the  femur  in 
children  and  young  adults.  i\ccording  to  Sprengel  and  others,  the 
resultant  deformity,  which  consists  of  a  bending  do^^^lward  and  back- 
ward of  the  neck,  is  due  to  an  epiphyseal  separation  which  may  be 
complete  or  incomplete. 

Whitman"  is  of  the  opinion  that  the  injury  is  a  true  fracture  of 
the  neck  and  only  rarely  a  separation  of  the  neck  from  the  head  at 


Fig.  330. — X-RAY  OF  Fracture  of  Rim  of  Acetabulum. 
AR,  Fragment  of  rim  of  acetabulum,  which  has  been  displaced  upward  and  backward;  HF,  head  of  femur 
which  has  been  allowed  to  be  displaced  through  the  absence  of  the  acetabular  rim,  thus  causing  a  backward  and 
upward  dislocation  of  the  hip-joint. 


their  junction  (Fig.  445).  In  the  majority  of  cases  the  lesion  is  undoubt- 
edly one  of  epiphyseal  separation.  In  both  epiphyseal  separations  and 
fractures  of  the  neck  the  condition  may  follow  even  a  slight  trauma  and 
result  in  the  deformity  known  as  coxa  vara  (page  648). 

In  children  fracture  of  the  neck  can  be  distinguished  clinically  and  with 
the  rv-ray  from  epiphyseal  separation,  according  to  Whitman,  as  follows: 

In  fracture  of  the  neck  there  is  more  shortening,  less  outward  rota- 

'  "  Archiv  fur  klinische  Chirurgie,"  Bd.  Ivii.        '  "Medical  Record,"  March  lo,  1904. 


;oo 


THE    EXTREMITIES. 


tion,  and  the  trochanter  is  more  prominent.  Motion  at  the  hip-joint 
is  practically  free,  except  in  abduction,  which  is  particularly  restricted 
when  the  hmb  is  flexed. 

In  epiphyseal  separation  the  shortening  is  less,  the  outward  rota- 
tion greater.  Frequently  there  is  a  sweUing  to  be  felt  over  Scarpa's 
triangle  over  the  position  of  the  head.  The  trochanter  is  not  as  promi- 
nent, but  motions  at  the  hip-joint  are  always  more  restricted,  due  to 


Fig.  331.— Most  Frequent  Conditions  to  be  Considered  in  Differential  Dl^gnosis  of  Injuries  of 

THE  Hip-joint. 
I,  Backward  and  upward  dislocation  of  the  head  of  femur  ;  2,  forward  dislocation  of  head  of  femur  ;  3,  fracture 

of  neck  of  femur. 


dislocation  of  the  head  and  to  the  reflex  muscle  spasm  resulting  from 
the  traumatic  synovitis. 

The  cases  are  often  seen  months  to  years  after  the  accident,  when  the 
resultant  coxa  vara  is  the  most  prominent  sign.  x\t  such  a  period  it  is  im- 
possible to  dift'erentiate  a  coxa  vara  traumaticum  from  a  true  coxa  vara. 

Fractures  of  the  Femur.— The  diagnosis  of  these  fractures  usually 
presents  no  difficukies.  Their  recognition  is  easier  when  the  fracture  is 
a  complete  one  and  the  periosteum  has  been  torn.  In  such  patients  the 
usual  signs  of  fractures,  viz.,  abnormal  mobility,  deformity,  crepitus, 
loss  of  function,  and  pain  are  quite  marked. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


;oi 


If  the  fracture  is  incomplete  or  the  periosteum  has  not  been  torn,  as  not 
infrequently  occurs  in  children,  especially  in  those  suffering  from  scurvy 
or  rachitis,  the  diagnosis  is  far  more  difficult.  This  is  due  to  the  fact  that 
there  is  but  Httle  deformity  and  the  diagnosis  depends  chiefly  upon  the 
elicitation  of  crepitus  and  abnormal  mobility  combined  with  localized 
pain  and  loss  of  function. 

Fractures  oj  the  shaft  are  divided  into  those  (a)  of  the  upper,  (b)  of 
the  middle,  and  (c)  of  the  lower  third.  In  fractures  of  the  upper  third 
the  line  of  fracture  is  most  oblique,  the  upper  fragment  being  displaced 
upward  and  forward  and  the 
lower  one  upward  and  inward 
(Fig.  334),  resulting  in  a  greater 
degree  of  shortening  than  is 
present  in  fracture  of  the  other 
two-thirds. 

In  fractures  of  the  middle 
third  the  line  of  fracture  is  either 
oblique  or  spiral  in  direction. 
Even  in  healthy  children  the 
periosteum  often  remains  untom 
in  fractures  at  this  level.  Both 
fragments  are  usually  displaced 
outward,  forming  an  angle,  or 
there  is  considerable  overlapping 
of  the  fragments. 

In  fractures  of  the  lower 
third  the  hne  of  fracture  is 
oftener  transverse  and  the  upper 
fragment  overrides  the  lower, 
there  being  but  little  tendency 
to  outward  displacement. 

The  diagnosis  of  fractures  of  the  shaft  depends  to  a  great  extent  upon 
the  recognition  of  the  deformity  and  shortening  which  result  from  the 
displacement  of  fragments.  This  is  often  so  marked  and  \'isible  as  to 
require  but  httle  manipulation. 

The  degree  of  shortening  can  be  determined  by  measurement  of  the 
limbs  from  the  anterior  superior  spine  of  the  ilium  to  the  lower  border  of 
the  inner  malleolus,  and  comparison  with  that  of  the  opposite  hmb. 
Both  hmbs  should  form  the  same  angle  with  the  pelvis  when  the  measure- 
ments are  made  and  should  be  brought  as  close  to  the  median  line  of  the 
body  as  possible. 


Fig.  332. 


Location  of  Head  in  Various  Forms  of 
Dislocation  of  Hip. 


502 


THE    EXTREMITIES. 


Abnormal  mobility  and  crepitus  are  most  marked  in  fractures  of  the 
upper  and  middle  thirds,  especially  if  complete,  and  can  be  best  elicited 
by  grasping  the  Hmb  in  the  manner  shown  in  Fig.  334. 

The  projecting  ends  of  the  upper  and  lower  fragments  can  often  be  felt 
beneath  the  skin  in  simple  fractures  or  projecting  through  it  in  compound 
fractures.  In  fractures  of  the  lower  third  the  diagnosis  is  more  difficult, 
on  account   of  the  accompanying  effusion  into  the  knee-joint  and  the 


Fig.  333. — Method  of  Measuring  the  Length  of  thz  Two  Limbs  rs"  a  Case  of  Fbacture  of  the  Shaft 

OR  OF  the  XeCK  of  THE  FeMXTR. 

\Miile  the  patient  is  lying  upon  his  back,  three  points  should  be  marked  on  each  limb,  as  shown  in  the 
illustration,  namely,  the  anterior  superior  spine  of  the  Uium,  the  middle  of  the  patella,  and  the  lower  border 
of  the  inner  malleolus.  There  may  be  apparent  shortening  due  to  the  elevation  of  the  pehis,  as 
shown  in  the  illustration.  The  method  of  measurement  consists  in  placing  one  end  of  a  steel  tape-measure  on 
the  anterior  superior  spine,  and  the  other  across  the  line  drawn  just  below  the  inner  malleolus.  The  tape- 
measure  should  pass  exactly  through  the  hne  drawn  in  a  vertical  maimer  through  the  middle  of  the  patella. 
In  the  illustration  this  latter  line  has  been  purposely  shown  a  Uttle  to  the  Loner  side  of  the  tape-measure.  The 
outward  rotation  of  the  limb  in  fractures  of  the  shaft  of  the  femur  is  well  shown  in  this  patient. 


slighter  degree  of  displacement  of  fragments.     There  is  usually,  how- 
ever, marked  loss  of  function,  swelHng,  and  some  degree  of  deformity. 

In  ever}-  case  in  which  the  diagnosis  of  fracture  of  the  lower  third 
of  the  femur  Csupracondyloidj  has  been  made  an  examination  of  the  limb 
distal  to  the  knee  should  be  made.  This  should  include  (a)  the  pal- 
pation of  the  superficial  arteries,  like  the  dorsahs  pedis  and  posterior 
tibial,  for  loss  of  pulsation  as  the  result  of  injury  of  the  popliteal  arter}^ 
and  (b)  the  changes  in  color  of  the  limb,  swelling,  etc.,  which  might 
result  from  compression  and  thrombosis  of  the  popKteal  vein  (Fig.  266). 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


503 


Fractures  of  the  Lower  End  0}  the  Femur. — These  greatly  resemble 
those  of  the  lower  end  of  the  humerus.  They  are:  (a)  Intercondyloid; 
(b)  fractures  of  either  condyle;  and  (c)  separation  of  the  lower  epiphysis. 

In  the  intercondyloid  variety  the  line  of  fracture  is  either  T-  or  Y- 
shaped,  is  very  apt  to  be  compound  and  associated  with  injury  of  the 
popliteal  vessels.  The  diagnosis  is  made  from  the  independent  mobility 
of  the  two  condyles  on  each  other,  when  they  are  moved  backward  and  for- 
ward, and  by  the  pain,  when  they  are  pressed  together.  Effusion  into  the 
knee-joint  is  constant  and  often  obscures  the  recognition  of  the  fracture. 
Separation  of  either  condyle  is  not  accompanied  by  any  shortening.     It 


Fig.  334. — Method  of  Examination  for  Fracture  of  Shaft  of  Femur. 
The  injured  thigh  is  laid  upon  the  outstretched  hand  of  the  examiner,  with  palm  upward,  while  the  opposite 
hand  grasps  the  middle  of  the  leg.  \\'hile  the  hand  which  is  supporting  the  point  of  fracture  fixes  the  thigh  to 
some  extent,  the  opposite  hand  by  a  motion  to  and  away  from  the  median  Une  of  the  body  enables  one  to  deter- 
mine the  false  point  of  motion.  In  this  illustration  the  forward  bowing  of  the  limb  due  to  slipping  of  the  frag- 
ments past  each  other  is  well  shown,  causing  considerable  shortening  of  the  hmb. 


is  quite  rare  and  is  usually  overlooked  because  there  is  but  little  displace- 
ment. Separation  of  the  lower  epiphysis  of  the  femur  is  next  in  order 
of  frequency  to  epiphyseal  separation  of  the  upper  end  of  the  humerus. 
The  epiphysis  is  usually  displaced  forward  and  the  shaft  pulled  back- 
ward by  the  gastrocnemius  muscle.  The  latter  displacement  may  in 
some  cases  endanger  the  popliteal  vessels,  as  in  supracondyloid  fracture 
(Fig.  266). 

The  diagnosis  can  be  made  from  (a)  the  presence  of  abnormal  mo- 
bility in  a  young  person,  just  above  the  knee-joint;  (b)  the  palpation  of 
the  two  fragments,  the  lower  in  front  of  the  upper,  and  (c)  the  elicitation 


504  THE    EXTREMITIES. 

of  a  soft  cartilaginous  crepitus.  One  should  never  neglect  to  search  for 
absence  of  pulsation  of  the  superficial  arteries  below  the  point  of  fracture 
and  note  any  changes  in  the  color  of  the  limb. 

Injuries  in  the  Vicinity  of  the  Knee-joint. — These  include: 

1 .  Fractures  and  epiphyseal  separation  at  the  lower  end  of  the  femur. 

2.  (a)  Fractures  or  (b)  dislocation  of  the  patella. 

3.  Dislocations  of  the  knee  (upper  end  of  the  tibia). 

4.  Fractures  of  the  upper  end  of  the  (a)  tibia  and  (b)  fibula. 

5.  Sprain  or  otherinjuries  of  the  knee-joint  proper  and  of  its  ligaments. 


X 


Fig.  335. — Method  of  Determining  Abnormal  Lateral  Mobility  of  Knee-joint,  Due  to  Tearing 
OR  Stretching  of  the  Lateral  Ligaments. 
The  patient  while  lying  down  is  grasped  so  that  the  knee  rests  upon  the  palm  of  the  examiner's  right  hand, 
if  the  left  limb  is  to  be  examined,  and  vice  versa  in  the  case  of  the  right  limb,  while  the  opposite  hand  grasps  the 
leg  at  about  its  middle,  the  object  being  to  fix  the  knee  more  or  less  with  the  hand  beneath  it,  while  the  other  hand 
by  to-and-fro  motions  determines  any  increase  in  lateral  mobility. 


In  every  case  of  injury  in  the  vicinity  of  the  knee  one  must  exclude  all 
of  the  above  named  injuries  through  systematic  examination  as  follows: 

(a)  Inspection.  This  will  often  show  at  once  the  presence  of  a  de- 
formity, changes  in  color  of  the  limb  due  to  vessel  injury,  or  the  swelling 
of  the  knee-joint  proper  with  obliteration  of  its  normal  depressions  (Fig. 
336)  on  either  side  of  the  patella. 

(b)  Palpation  and  manipulation.  This  wih  show:  (i)  the  presence  of 
fluid  in  the  knee-joint  by  ballotement  of  the  patella  (Fig.  335)  and  meas- 
urement of  the  circumference;  (2)  palpation  of  the  surface  of  and  position 
of  the  patella  will  show  the  presence  or  absence  of  a  fracture  or  dislocation 
of  this  bone;  (3)  manipulation  of  the  knee  as  shown  in  Fig.  335  will  reveal 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


505 


the  presence  of  abnormal  mobility  due  to  laceration  of  the  lateral  liga- 
ments; (4)  palpation  and  manipulation  of  the  lower  end  of  the  femur  and 
upper  end  of  the  bones  of  the  leg  will  reveal  the  presence  or  absence  of  ab- 
normal relation  to  each  other,  as  in  dislocation  of  the  knee,  or  of  abnor- 
mal mobility,  deformity,  or  crepitus,  as  in  fractures  or  epiphyseal 
separation. 

The  methods  of  examination  for  ruptured  ligamentum  patellae  and  for 
injuries  of  the  semilunar  cartilages  have  been  previously  given. 

The  principal  diagnostic  points 
of  the  above  named  injuries  are  as 
follows : 

1.  Fractures  and  Epiphyseal 
Separation  of  the  Lower  End  of  the 
Femur. — (See  page  503.) 

2.  (a)  Fractures  of  the  Patella. 
— There  is  usually  great  swelling 
of  the  knee,  most  marked  about 
six  to  eight  hours  after  the  accident. 
Unless  this  effusion  into  the  knee  is 
too  extensive,  it  is  possible  to  feel  a 
hiatus  or  gap  in  the  patella  and  to 
move  the  two  fragments  indepen- 
dently of  each  other,  by  grasping 
them  between  the  thumb  and  in- 
dex-fingers. Crepitus  can  often  be 
elicited  by  this  manipulation.  If 
the  fragments  are  close  together, 
both  of  these  signs  are  less 
marked.  __  The  patient  is  unable 
to  extend  the  limb,  and  there 
is  usually  great  pain  in  the  knee, 

especially  when  the  fragments  are  pressed  together  or  the  limb  is  flexed. 
2.  (b)  Dislocations  of  the  Patella. — These  are  c[uitc  rare,  forming  about 
one  per  cent,  of  all  forms  of  dfslocation.  Dislocation  may  occur  out- 
ward, inward,  or  edgewise  (vertical).  Of  these,  the  outward  variety  is 
the  most  frequent.  The  knee  appears  flatter  and  broader  than  usual 
and  the  intercondyloid  notch  is  quite  prominent.  The  patella  can  be 
felt  on  the  outer  side  of  the  condyle,  and  at  its  upper  and  lower  ends 
respectively  the  quadriceps  tendon  and  ligamentum  ])atclkc  can  be  felt 
as  tense  bands.  The  inward  and  vertical  forms  are  rare  and  their  recog- 
nition is  similar  to  that  of  the  outward  form. 


Fig.  336. — Case:  Fracture  of  the  Patella. 

Moderate   separation  of  the  fragments  of  each 

knee-joint.     Useful  legs  (Scudder). 


5o6 


THE    EXTREMITIES. 


3.  Dislocations  of  the  Knee. — These  are  as  rare  as  those  of  the  patella. 
This  form  of  dislocation  is  very  rare  in  children.  Dislocations  of  the 
knee  are  divided,  according  to  the  direction  in  which  the  tibia  is  dis- 
placed, into  forward,  backward,  outward,  and  inward  varieties,  and 
there  is  a  fifth  form,  or  dislocation  by  rotation.  The  lateral  (outward 
and  inward)  varieties  are  usually  associated  with  more  or  less  rotation. 
Dislocation  forward  is  the  most  frequent  of  all  and  can  be  readily  recog- 
nized. The  tibia  lies  in  a  plane  in  front  of  that  of  the  thigh.  The  out- 
line of  the  tibia  can  be  seen  and  felt  lying  in  front  of  the  lower  end  of  the 
femur,  the  latter  being  prominent  in  the  popliteal  space.  The  limb  may 
be  fixed  or  movable  in  any  direction.     There  may  be  evidences  of  injury 

of  the  popliteal  artery 
and  of  the  internal  pop- 
liteal nerve;  the  former 
can  be  recognized  by 
the  loss  of  pulsation  and 
the  latter  by  the  loss  of 
sensation  (pages  430  and 

434)- 

In  the  backward  var- 
iety the  above  signs  are 
reversed.  The  head  of 
the  tibia  lies  behind  the 
condyles  of  the  femur 
and  can  be  felt  in  the 
popliteal  space.  There 
is  a  marked  depression 
below  the  condyles  of 
the  femur  in  front  of  the  knee.  Injury  of  the  pophteal  vessels  is  even 
more  frequent  than  in  the  forward  variety. 

Lateral  dislocations  are  quite  rare  and  their  recognition  is  not  dif- 
ficult, the  outer  part  of  the  head  of  the  tibia  projecting  on  the  outer  side 
of  the  joint  in  the  outward  and  in  the  opposite  manner  in  the  inward 
variety. 

4.  Fractures  of  the  Upper  End  of  the  Tibia  and  Fibula. — Fractures 
of  the  upper  end  of  the  tibia  usually  extend  into  the  knee-joint.  The 
most  frequent  form  is  that  in  which  the  hne  of  fracture  is  oblique  and 
results  in  the  separation  of  either  the  internal  or  external  condyle  from 
the  remainder  of  the  bone  (Fig.  338).  In  addition  to  the  oblique  frac- 
tures of  the  condyles,  transverse  and  longitudinal  fractures  occur,  but 
are  comparatively  infrequent.     A  form  of  compression  fracture  has  also 


Fig.  337. — Outward  Dislocation  of  the  Patella  (Hoffa). 


SPECIAL   FRACTURES   AND   DISLOCATIONS. 


507 


been  described  by  Wagner  of  Konigshiitte,  in  which  there  is  a  fracture 
of  either  condyle  and  more  or  less  marked  crushing  of  the  head  of  the 
tibia  after  a  fall  upon  the  foot. 


Fig.  338. — Various  Forms  of  Fractures  or  the  Upper  End  of  the  Tibia  and  Fibula  Near  the 

Knee-joint. 
A,  Fracture  of  the  upper  end  of  the  fibula  alone.  B,  Fracture  passing  through  the  outer  tuberosity  of  the 
knee-joint,  accompanied  by  fracture  of  the  upper  end  of  the  fibula  close  to  its  head.  C,  Fracture  passing 
through  the  inner  tuberosity  of  the  tibia,  with  displacement  of  the  leg  outward,  resulting  in  a  genu  valgum 
position.  D,  Multiple  crushing  fracture  of  the  outer  tuberosity  of  the  tibia.  E,  Multiple  crushing  fracture 
of  the  upper  end  of  the  tibia,  extending  into  knee-joint.  The  lower  fragment  composed  of  the  shaft  is  forced 
upward  between  the  two  upper  fragments,  composed  of  the  tuberosities.  F,  Side  view  of  separation  of  upper 
epiphysis  of  tibia  and  the  beak-shaped  process  of  same. 


The  diagnosis  of  a  fracture  of  the  upper  end  of  the  tibia  is  often 
impossible  without  the  aid  of  an  anesthetic  and  the  .v-rav.     In  almost 


5o8 


THE    EXTREMITIES. 


every  case  the  accompanying  effusion  into  the  knee-joint  is  so  marked 
after  a  few  hours  as  to  render  an  examination  ver}'  difficuh. 

In  fractures  involving  one  of  the  condyles  abnormal  mobility  of  the 
knee  either  in  an  inward  or  outward  direction  will  be  found  when  the 
knee  is  manipulated  in  the  manner  shoTMi  in  Fig.  335.  There  is  great 
pain   on  pressure  over   the   fractured   condyle.     If   the   internal   con- 


.SI  6. 


Fig.  339. — Various  Forms  of  Fractures  in  Lower  Third  of  Leg. 
\\'ash  drawings  made  from  skiagraphs,     i,  Fracture  of  internal  malleolus;    2,  comminuted  fracture  of 
tibia  and  fibula  at  junction  of  lower  and  middle  third;    3,  oblique  fracture  of  tibia  with  displacement  of 
upper  fragments  outward;     4,  oblique  fracture  of  tibia  -nnthout    displacement;    5,  spiral  fracture   of   lower 
third  of  tibia;    6,  fracture  of  external  malleolus. 


dyle  is  involved,  there  is  abnormal  mobility  at  the  knee  in  an  inward 
direction  or  the  limb  is  found  in  a  genu  varum  position.  If  the 
external  condyle  is  broken,  abnormal  mobility  in  an  outward  direction  is 
to  be  found  and  the  limb  is  held  in  a  genu  valgum  position.  Unless  the 
swelling  of  the  knee-joint  is  too  great,  one  can  palpate  the  displaced  con- 
dyle and  in  some  cases  elicit  distinct  crepitus. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


509 


If  both  condyles  have  been  broken  and  the  shaft  has  been  displaced 
upward  between  them,  there  is  widening  of  the  knee-joint. 

Separation  of  the  upper  epiphysis  of  the  tibia,  of  which  twenty-six 
cases  have  been  reported,  is,  like  that  of  the  lower  epiphysis  of  the  femur, 
a  serious  and  often  fatal  injury. 

The  swelhng  of  the  knee-joint  is  usually  considerable.  Mobility  of 
the  epiphysis,  most  notice- 
able in  a  lateral  direction, 
is,  as  in  other  epiphyseal 
separations,  the  most  trust- 
worthy sign,  according  to 
Poland.  Crepitus  of  a 
soft  m.uffled  character  can 
be  detected  in  many  of  the 
simpler  cases  in  which 
mobility  of  the  epiphysis 
is  present.  Dislocation  of 
the  knee  is  scarcely  known 
in  children  and  the  free 
movement  of  the  joint  in 
cases  of  separation  suf- 
fices to  exclude  this  form 
of  injury.  When  there  is 
httle  or  no  displacement  or 
mobility,  the  injury  may  be 
mistaken  for  a  sprain  of 
the  knee.  Osgood  has 
recently  called  attention  to 
a  peculiar  partial  separa- 
tion of  the  tongue-shaped 
portion  of  the  upper  tibial 
epiphysis  in  young  ath- 
letes. CUnically  acute  pain 
is  felt  in  the  knee,  referred  to  below  the  patella.  It  is  accompanied  by 
shght  swelling  of  the  joint  and  there  is  considerable  weakness  on  exertion. 

Avulsion  of  the  tubercle  of  the  tibia  occurs  in  the  young.  The  diag- 
nosis can  be  made  by  the  recognition  of  independent  mobility  of  the 
tubercle,  inabihty  to  use  the  hmb,  and  swelling  of  the  knee-joint. 

In  some  cases  there  is  only  local  pain  and  tenderness  and  the  diag- 
nosis cannot  be  made  without  the  aid  of  a  skiagraph. 

Fractures  oj  the  upper  end  of  the  fibula  occur  either  through  muscular 


Fig.  340. — Compound    (Gunshot)   Comminuted   Fracture 
OF  THE  Lower  Third  of  the  Tibia  and  Fibula. 
The  line  passing  across  the  upper  portion  of  the  plate  is  due 
to  a  defect.      The  black  particles  of  the  bullet  fragments  are 
well  shown  lying  over  the  front  of  ihc  tibia. 


5IO 


THE    EXTREMITIES. 


action  of  the  biceps  or  more  commonly  through  forcible  adduction  of 
the  leg.  The  injury  may  be  recognized  by  the  presence  of  pain  just 
below  the  head  of  the  fibula,  accompanied  by  the  presence  of  a  small,  hard 
mass,  movable  from  side  to  side,  which  is  raised  by  extension,  but  sinks 
after  flexion  of  the  knee-joint.     There  is  also  abnormal  lateral  mobility 


Fig.  341. — X-RAY  OF  Case  of  Fracture  of  Both  Bones  of  the  Leg,  the  Exterior  Pictures  of  Which  are 

Shown  in  Figs.  343  and  344. 
Note  the  voluminous  callus  formation  in  the  tibia,  and  the  displacement  inward  of  both  lower  fragments  and  of 

the  foot. 


of  the  knee-joint.  Not  infrequently  the  injury  is  followed  by  paralysis 
of  the  muscles  (peronei)  supplied  by  the  peroneal  nerve,  causing  inabil- 
ity to  raise  the  outer  border  of  the  foot. 

Fractures  of  the  Shaft  of  the  Tibia. — These  occur  more  frequently 
after  direct  injuries  (when  the  limb  is  run  over,  or  a  heavy  body  falls 
on  it)  than  after  indirect  injuries  (such  as  a  sudden  abduction  or  adduc- 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


511 


tion  of  foot) .  Both  bones  of  the  leg  are  usually  broken  after  indirect  vio- 
lence, complete  fractures  are  far  more  frequent  in  adults  than  in  children. 
The  line  of  fracture  is  most  often  obHque  (Fig.  339),  although  spiral 
fractures  have  been  found  in  about  one-seventh  of  all  of  the  cases.  This 
is  important  to  diagnose  by  the  use  of  the  .v-ray,  owing  to  the  fact  that 


Fig.  342. — X-RAY  OF  Same  Case  as  Shown  in  Figs.  341  and  343,  of  Fracture  of  Both  Bones  of  the  Leg 

Just  above  the  Ankle-joint. 
The  illustration  shows  the  characteristic  backward  displacement  of  the  foot  and  lower  fragments. 


in  the  spiral  form  the  fracture  is  much  more  dithcult  to  reduce  com- 
pletely. 

In  the  oblic{ue  form,  the  line  of  fracture  runs  from  below  and  anteriorly 
backward  and  upward,  so  that  the  upper  fragment  is  often  displaced  for- 
ward to  such  an  extent  as  to  lie  directly  beneath  the  skin. 

Comminuted  fractures,  especially  of  the  lower  end  of  the  tibia  and 


THE   EXTREMITIES. 


fibula,  are  not  uncommon.     The  diagnosis  of  a  jracfure  of  the  shajt  of 
one  or  both  hones  of  the  leg  is,  as  a  rule,  not  difficult. 

In  many  cases  the  deformity  at  the  point  of  fracture  and  the  outward 
rotation  of  the  foot  will  permit  a  diagnosis  to  be  made  from  inspection 
alone.     In  some  cases  of  compound  fracture  the  ends  of  the  fragments 

project  through  the  skin. 
By  gently  grasping  the 
limb  while  the  assistant 
supports  the  knee  or  an- 
kle, abnormal  mobiHty 
and  crepitus  can  be  read- 
ily elicited. 

Shortening  of  the 
limb  can  be  estimated 
by  measurement  from 
the  upper  border  of  the 
inner  tuberosity  of  the 
tibia  to  the  tip  of  the 
inner  malleolus.  The 
finger  should  also  be 
passed  along  the  tibia 
and  fibula  wherever  they 
he  beneath  the  skin  in  or- 
der to  detect  any  irregu- 
larity. In  a  few  cases 
where  the  broken  ends 
are  dentated  and  dis- 
placed but  little,  one  must 
be  content,  in  the  absence 
of  a  skiagraph,  with  mak- 
ing a  diagnosis  from  the 
presence  of  locahzed  pain 
and  swelling  followed  by 
loss  of  function. 
When  both  bones  are  broken  the  abnormal  mobility  is  usually  much 
greater  than  is  the  case  if  the  tibia  alone  is  fractured.  Isolated  fractures 
of  the  upper  and  middle  thirds  of  the  shaft  of  the  fibula  are  relatively  rare. 
The  diagnosis  of  such  fractures  depends  upon  the  localized  pain  and  the 
elicitation  of  crepitus  and  abnormal  mobility  on  pressure. 

It  is  of  the  greatest  importance  to  combine  the  use  of  the  .'V-ray  with 
the  above  outlined  external  examination.     It  reveals  many  cases  of  in- 


\^^^ 


Fig.  343. — .\^-TERiOR  View  of  Deformity  Following  Pott's 
Fracture. 
Note  the  change  in  the  axis  of  the  right  or  injured  hmb  from 
the  middle  of  the  leg  downward.  This  deformity  was  due  to  the 
displacement  inward  of  the  lower  fragments  of  the  tibia  and  fibula 
respectively. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


513 


complete  or  subperiosteal  fractures  where  none  were  suspected.  It  also 
yields  much  information  as  to  the  degree  of  displacement  and  the  direc- 
tion of  the  line  of  fracture,  whether  spiral,  oblique,  or  transverse. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  more  frequent 
than  is  that  of  the  upper.  Deformity  is  the  most  marked  sign, 
the  foot  and  the  epiphysis  being  displaced  backward.  The  internal 
malleolus  preser^-es  its  normal  relations  with  the  foot,  but  not  w^ith  the 


Fig.  344. — View  from  Outer  Side  of  Deformity  Following  Pott's  Fracture. 
Note  the  prominence  of  the  external  malleolus,  due  to  the  displacement  outward  of  both  upper  fragments, 

that  is,  o£  the  tibia  and  fibula. 


rest  of  the  leg  or  the  external  malleolus.  In  gunshot  fractures  (Fig.  340) 
of  the  leg,  the  comminution  of  the  tibia  is  usually  much  more  extensive 
than  is  thought  from  external  examination. 

Injuries  in  the  Vicinity  of  the  Ankle-joint. — In  the  examination 
of  a  patient  who  shows  evidences  of  injury  in  the  Aicinity  of  the  ankle- 
joint,  such  as  swelling,  deformity,  loss  of  function,  etc.,  the  following 
conditions  must  be  thoufjht  of  and  excluded,  in  the  order  s:iN'en: 


514 


THE    EXTREMITIES. 


Fractures  of  the  lower  ends  of  the  tibia  and  fibula  (Pott's  fracture). 

Dislocations  at  or  near  the  ankle. 

Fractures  of  the  tarsal  bones. 

Rupture  of  the  tendo  Achilhs.     (See  page  426.) 
5.  Sprains  of  the  ankle. ^     (See  page  450.) 

I.  Fractures  of  the  Lower  End  of  the  Tibia  and  Fibula. — These 
are  all  given  the  name  of  Pott's  fracture.     They  may  be  the  result  either 


Fig.  345. — View  of  a  Deformity  Following  Pott's  Fracture  from  the  Inner  Side. 
Note  the  bowing  forward  at  the  lower  third  of  the  anterior  aspect  of  the  leg.     The  arrow  points  to  a  fre- 
quent comphcation  of  fractures  of  the  lower  third  of  the  tibia  and  fibula,  namely,  traumatic  flat-foot.     This  is 
the  same  case  as  is  shown  in  Fig.  344. 


(a)  of  forcible  abduction  or  eversion  of  the  foot,  or  (b)  of  inversion  or  ad- 
duction. If  the  sole  or  main  movement  is  eversion  the  internal  malleolus 
is  broken,  and  if  the  force  continues  to  act  it  also  causes  the  external 
malleolus  to  be  broken.  In  the  second  variety,  i.  e.,  fracture  by  inver- 
sion, the  first  effect  of  the  force  is  to  break  the  fibula  (external  mal- 
leolus). If  the  movement  continues,  the  internal  malleolus  or  a  greater 
portion  of  the  tibia  is  broken  off. 

^  Sprains  of  the  ankle  are  not  infrequently  accompanied  by  fractures  of  the  lower  end 
of  the  tibia  and  fibula  which  can  only  be  recognized  if  an  rv-ray  be  taken. 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


515 


There  is  usually  no  difficulty  in  making  a  diagnosis.  The  ankle-joint 
is  greatly  swollen,  the  depression  normally  present,  in  front  of  and  behind 
the  malleoli,  being  obhterated.  The  foot  is  displaced  outward  and  the 
internal  malleolus  is  prominent.  This  deformity  will  often  persist  and 
become  a  cause  of  disabihty  after  heahng  of  the  fracture  (Fig.  343). 
There  is  also  backward  displacement  of  the  foot  (Fig.  344). 

These  displacements  may  be  so  marked  as  to  resemble  a  true  dislo- 


FiG.  346. — Fracture  of  Both  Bones  of  the  Leg  with  Marked  Backward  Displacement. 


cation  of  the  ankle  at  lirst  glance.  Abnormal  lateral  and  anlero-pos- 
terior  mobility  may  be  ascertained  by  grasping  the  sole  of  tlie  foot  (Fig. 
349)  with  one  hand  and  moving  it  inward  or  outward  or  backward  and 
forward  while  the  other  hand  steadies  the  leg.  'Hiere  is  great  tender- 
ness between  the  tibia  and  fibula  at  tlie  front  of  the  ankle  and  over  the 
points  of  fracture  in  tlie  malleoli. 

If  the  ril)ula  alone  is  broken,  abnormal  mobilit}-  and  cre])itus  may  be 


;i6 


THE    EXTREMITIES. 


elicited  by  pressing  its  tip  inward  with  the  index-iinger  of  one  hand  (Fig. 
348)  while  a  finger  of  the  other  hand  is  placed  at  the  seat  of  fracture. 

In  some  cases  of  Pott's  fracture  the  foot  will  move  inward  instead  of 
outward.  The  degree  of  backward  displacement  can  be  measured  by  the 
difference  in  the  distance  from  the  front  of  the  ankle  to  the  cleft  between 
the  first  and  second  toes  as  measured  on  the  sound  and  on  the  injured 

foot.  There  is  not  always  com- 
plete loss  of  function.  In  frac- 
tures of  the  external  malleolus 
alone  the  patient  may  walk 
c[uite  well. 

2.  Dislocations  at  or 
Near  the  Ankle. — These  in- 
juries are  very  rare,  constitut- 
ing, according  to  the  statistics 
of  Kronlein,  only  about  0.5  per 
cent,  of  all  forms  of  disloca- 
tions. The  displacement  may 
be  complete  or  incomplete,  the 
latter  occurring  more  frequent- 
ly. Dislocations  at  the  ankle 
are  often  associated  with  frac- 
tures of  one  or  both  bones  of 
the  leg,  especially  of  the  mal- 
leoli. 

Dislocations  at  the  Ankle- 
joint  {Tibiotarsal  Disloca- 
tions).— They  are  best  divided 
{a)  into  those  which  occur  in 
a  sagittal  direction,  z.  e.,  for- 
ward or  backward,  and  {h) 
into  those  which  take  place 
laterally,  i.  e.,  outward  or  in- 
ward. 
(a)  Dislocations  in  a  Sagittal  Direction. — In  the  forward  variety 
(Fig.  351)  the  whole  foot  appears  to  be  lengthened.  The  prominence 
due  to  the  heel  has  disappeared.  The  upper  articular  surface  of  the 
astragalus  can  be  felt,  and  the  malleoh  are  nearer  to  the  heel.  It 
can  be  differentiated  from  a  fracture  of  both  bones  of  the  leg  above  the 
malleoh  bv  the  fact  that  in  a  forward  dislocation  the  malleoh  are  further 


Fig.  347. — Front  View  of  a  Recent  Pott's  Fracture, 
WITH  Slight  Displacement  of  Fragments. 
Note  the  swelling  of  the  lower  third  of  the  left  leg,  and 
the  obliteration  of  the  normal  depressions  over  the  front 
of  the  ankle-joint,  and  above  and  below  the  malleoli,  on 
the  left  or  injured  limb. 


SPECIAL    FRACTURES    AND   DISLOCATIONS. 


517 


back  than  normal,  while  in  a  supramalleolar  fracture  they  have  moved 
forward  with  the  foot. 

In  the  backward  variety,  the  findings  are  opposite  to  those  of  the 
forward.  The  front  portion  of  the  foot  is  shortened  (Fig.  351)  while 
the  heel  is  more  prominent  than  normal.  The  lower  end  of  the  tibia 
protrudes  over  the  dorsum  of  the  foot  and  the  sharp  edge  of  its  articular 
surface  is  to  be  felt  distinctly.  The  extensor  tendons  and  the  tendo 
Achillis  are  tense  and  prominent.  It  may  be  distinguished  from  a  supra- 
malleolar fracture  by  the  fact  that  the  malleoli  in  the  latter  have  moved 
backward  wdth  the  foot,  w^hile  in  a  dislocation  backw^ard  they  are  prom- 
inent at  some  distance  forw^ard  from  the  heel. 


Fig.  348. — One  of  the  Methods  of  Examination  in  Order  to  Determine  a  Fracture  of  the  External 

Malleolus. 
The  method  consists  in  making  pressure  upon  the  tip  of  the  malleolus,  as  shown  in  the  illustration,  with 
the  two  fingers  of  one  hand,  while  the  other  hand  is  placed  at  the  suspected  point  of  fracture.     The  hand  placed 
over  the  tip  presses  it  in  and  allows  it  to  spring  back,  thus  establishing  a  kind  of  lever  action,  which  permits 
the  other-fingers  to  detect  readily  a  false  point  of  motion. 


ih)  Dislocations  in  a  Laleral  Direction. — The  inward  \aricty  is  N'ery 
rare,  only  twenty-seven  cases  having  been  reported.  It  is  not  inf  rc(  [ucntly 
compound  or  associated  with  fractures  of  the  tarsal  bones  or  of  the  bones 
of  the  leg.  The  convex  upper  articular  surface  is  prominent  (Fig.  351) 
just  below  the  outer  malleolus. 

In  the  outward  variety  the  most  fixnpient  form  is  tliat  in  which  the 
foot  is  markedly  abducted,  much  more  so  than  in  an  ordinary  Pott's 
fracture.  The  inner  border  of  the  foot  points  upward  while  the  outer 
border  rests  upon  the  ground  or  table.  The  upper  articular  surface  of 
the  astragalus  is  to  l)e  felt  just  below  the  internal  malleolus.  A  few 
cases  have  been  reported.     The  abduction  is  so  extreme  that  the  toes 


5l8  THE   EXTREillTIES. 

point  directly  outward  (Fig.  351),  the  foot  forming  an  angle  of  90  degrees 
with  the  leg.  To  this  subvariety  the  term  rotation-outward  dislocation 
of  the  ankle  has  been  given. 

As  is  true  of  all  varieties  of  injuries  about  the  ankle  or  of  the  foot,  the 
:v-ray  has  been  of  the  greatest  aid  in  making  an  early  diagnosis  of  the 
nature  of  the  injury. 

Suhastragaloid  Dislocations. — These  occur  in  the  astragalo-calcaneal 
joint  (Fig.  352).  There  are  two  chief  forms:  \iz.,  {a)  the  true  suh- 
astragaloid, in  which  the  astragalus  remains  in  articulation  with  the  tibia 
and  fibula  but  is  displaced  from  its  articulation  with  the  calcaneus.  In 
the  other  form  ih)  the  astragalus  is  completely  separated  from  its  re- 


FiG.  349.  —  Method  of  Ex.-iiiiNATiON  for  Fracture  of  the  Tibl\  or  of  Both  Bones  of  the  Leg 

Close  to  the  Ankle-joint. 
The  foot  is  grasped  by  the  left  hand  of  the  examiner  when  fracture  of  the  left  leg  is  suspected,  while  the 
right  hand  grasps  the  region  just  above  the  malleoli,  so  as  to  steady  the  limb  during  the  time  that  the  foot  is 
being  tiurned  toward  or  away  from  the  median  line  of  the  body,  in  order  to  determine  false  point  of  motion  and 
crepitus. 

lations  to  the  bones  of  the  leg  and  calcaneus.  This  latter  is  called 
"total  dislocation  of  the  astragalus."  The  true  suhastragaloid  disloca- 
tion may  occur  in  one  of  four  directions,  viz.,  inward,  outward,  forward, 
and  backward. 

The  most  frequent  of  these -(thirteen  out  of  twenty  cases  reported)  is 
the  outward  variety.  They  follow  forced  abduction  of  the  foot,  especially 
a  fall  upon  the  heel,  while  the  foot  is  excessively  abducted,  or  a  blow  upon 
the  outer  side  of  the  leg  , while  the  foot  is  fixed.  The  position  of  the  foot 
is  that  of  a  well-marked  case  of  flat-foot.  The  internal  malleolus  is 
nearer  to  the  sole  of  the  foot.  In  front  of  this  malleolus,  the  head  of  the 
astragalus  forms  a  prominence  and  the  scaphoid  is  to  be  distinctly  felt 


SPECIAL    FRACTURES    AND    DISLOCATIONS.  519 

upon  the  sole  of  the  foot.     The  injury  is  not  infrequently  compound,  so 
that  the  astragalus  presents  in  the  wound. 

An  important  point  in  tlie  diagnosis  of  subastragaloid  dislocation  is 
the  absence  of  any  prominence  due  to  the  projection  of  the  body  of  the 
astragalus  in  front,  behind,  or  on  either  side  of  the  malleoli,  as  is  the  case  in 
the  tibio-tarsal  dislocations  described  above.  Another  fact  is  the  ab- 
normal position  of  the  calcaneus  and  scaphoid  with  relation  to  the  mal- 


FiG.  350. — Lateral  View  of  Amount  of  Fixation  of  Ankle-joint  Following  Many  Injuries  in  Close 

Proximity  to  the  Same. 
The  lower  one  of  the  two  Hmbs  shows  the  degree  of  extension  of  the  foot  on  the  uninjured  side.    On  the 
side  of  the  fracture  it  can  be  readily  seen  that  the  amount  of  extension  is  practically  lost,  and  that  the  foot  is 
fixed  at  a  right  angle  to  the  long  axis  of  the  leg. 

leoli  and  astragalus.  .  The  swelhng  is  usually  so  great  that  a  diagnosis  is 
very  difficult  without  the  use  of  the  .T-ray. 

Total  dislocation  of  the  astragalus  is  much  more  frequent  than  that 
of  the  tibio-tarsal  or  astragalo-calcaneal  joint.  The  most  frequent  form 
is  the  outward.  In  this  variety  the  foot  is  rotated  markedly  inward,  i.  e., 
adducted  and  inverted,  or  club-foot  position.  The  external  malleolus  is 
very  prominent,  and  below  it  one  can  feel  the  dislocated  astragalus. 

3.  Fractures  of  the  Tarsal  Bones. — After  a  fall  from  a  height  the 
tissues  around  the  ankle-joint  are  often  so  enormously  swollen  that  an 
exact  diagnosis  by  palpation  is  very  difficult.     If  by  a  systematic  exam- 


520 


THE   EXTREMITIES. 


ination  one  has  excluded  all  of  the  varieties  of  injuries, just  described, 
one  must  not  omit  a  careful  search,  aided  by  the  x-ray,  for  fractures 
of  the  astragalus  and  calcaneus.  These  have  been  frequently  over- 
looked, and  not  until  ankylosis  has  occurred  was  the  suspicion  aroused 
that  the  case  might  have  been  more  than  a  severe  sprain.  Fractures 
of  the  tarsal  bones,  especially  of  the  astragalus  and  calcaneus,  are  not 
infrequently  associated  with  one  of  the  other  injuries  around  the  ankle, 
viz.,  fractures  or  dislocations  of  the  tibia  and  fibula. 


Fig.  35 1. — Various  Forms  of  Dislocations  of  the  Ankle-jo ixt  (Hoffa). 
I,  Forward  dislocatioa  of  the  foot;    2,  backward  dislocation  of  the  foot,  associated  with  fracture  of  the 
fibula;   3,  outward  dislocation  of  the  foot,  associated  with  fracture  of  the  tibia  and  fibula;  4,  inward  disloca- 
tion of  the  foot,  associated  with  fracture  of  the  tibia  and  fibula.     (See  text.) 


The  diagnosis  of  fractures  of  the  astragalus  can  be  most  satisfactorily 
made  if  every  injury  about  the  ankle  is  systematically  examined  with  the 
x-rav.  If  there  is  no  displacement  of  fragments,  a  diagnosis  is  almost 
impossible  at  the  time  of  injury,  the  case  being  usually  diagnosed  as  a 
severe  sprain.  There  is,  however,  more  pain  on  pressure  and  upon  flex- 
ing the  foot,  than  is  the  case  in  a  sprain,  and  not  infrequently  crepitus  can 
be  ehcited.  If  there  is  displacement  of  fragments  the  diagnosis  is  a 
little  less  difficult,  since  one  can  at  times  feel  the  displaced  fragments.     In 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


521 


fractures  of  the  neck  of  the  astragalus,  the  foot  is  extended  and  supinated, 
while  in  those  of  the  head  or  body,  it  is  flattened  or  even  in  a  pes  valgus 
position,  the  malleoli  is  lower  than  normal,  especially  when  the  body 
is  greatly  comminuted  (Fig.  355). 

Fractures  oj  the  Os  Calcis. — These  are  divided  (a)  into  compression 
fractures  of  the  body;  (h)  tearing  fractures  of  the  tuberosity;  the 
latter  is  most  apt  to  occur,  as  in  the  patient  whose  x-ray  is  sho^^n  in  Fig. 


Fig.  352. — Various  Forms  or  Subastrac.aloid  Dislocation  of  the  Foot  (Hofia). 
1,  Outward;    2,  inward;   3,  backward;    4,  forward. 


354,  by  falhng  forward  while  the  heel  is  iixed,  and  is  often  associated 
with  a  tearing  off  of  the  attachment  of  the  tendo  Achillis  to  the  os  calcis. 
The  diagnosis  in  the  second  variety  is  easier  than  in  the  crushing  or 
compression  fractures  of  the  body  of  the  bone.  The  detached  fragment 
can  often  be  felt  just  l^eneath  the  skin  above  the  heel. 

In  both  varieties  the  depressions  below  the  malleoli  are  noticeably 
obhtcrated,  there  is  marked  swelling  of  the  entire  ankle  (Fig.  357)  and 


522 


THE    EXTREMITIES. 


enlargement  of  the  heel.  The  malleoh  lie  closer  to  the  sole  of  the  foot. 
There  is  marked  tenderness  on  pressure  of  the  calcaneus  and  severe  pain 
on  walking.  Passive  adduction  and  abduction  of  the  foot  are  espe- 
cially interfered  with  and  painful. 

In  both  tearing  and  compression  fractures  the  use  of  the  x-ray  is 
invaluable.  One  should,  however,  always  compare  this  skiagraph  with 
one  taken  of  the  normal  ankle  of  the  patient. 


Fig.  353- — X-RAY  OF  Normal  Foot  and  Ankle-joint  Viewed  from  the  Outer  Side. 
F,  Fibula;    T,  tibia;    i,  astragalus;    2,  os  calcis;    3,  scaphoid;    4,  cuboid;    5,  external  cuneiforin. 

Fractures  oj  the  Remaining  Tarsal  Bones  of  the  Metatarsals  and  of  the 
Phalanges  of  the  Toes. — These  occur  from  heavy  weights  falling  upon  the 
dorsum  of  the  foot  or  from  being  run  over.  Fractures  of  the  metatarsal 
bones  may  also  result  from  jumping  or  from  long  marches,  such  as 
soldiers  make. 

In  the  case  of  the  metatarsal  bones  the  diagnosis  is  made  from,  the 
presence  of  severe,  well  localized  pain,  swelhng,  and  not  infrequently 
crepitus  and  deformity.     Standing  upon  the  foot  causes  great  pain.    A 


SPECIAL    FRACTURES    AND    DISLOCATIONS. 


523 


traumatic  flat-foot  may  follow  this  form  of  fracture  or  large  calluses 
develop  on  the  sole  of  the  foot  over  the  seat  of  fracture.  Fractures  of 
the  phalanges  of  the  toes  are  usually  the  result  of  a  crushing  force  and 
are  often  compound.     The  diagnosis  is  readily  made  by  inspection  and 


Fig.   354. — Fracture  of   Os   Calcis   (a--rav)   by   Muscular   Violence. 
The  white  arrow  indicates  the  direction  of  traction  of  the  gastrocnemius  and  soleus  muscles.      The  black 
arrow  points  to  the  characteristic  elevation  of  the  skin  caused  by  the  displacement  upward  of  the  fragment  in 
such  cases,     i,  Fragment  of  os  calcis;  2,  main  portion  of  bone;  3,  astragalus;  4,  5,  and  6,  tarsal  bones  (cuboid, 
scaphoid,  and  cuneiform,  respectively). 


from  the  presence  of  a  false  point  of  motion  and  crepitus  on  manipula- 
tion. 

Dislocations  oj  the  Metatarsal  Bones. — These  may  be  either  com- 
plete or  incomplete  at  Lisfranc's  joint.  They  occur  most  often  in  an 
upward  direction  and  may  follow  such  injuries  as  Ijcing  run  over,  the 
fall  of  a  heavy  weight  u])on  the  foot,  or  forcil)le  lle.xion  of  the  foot.  The 
dorsum  of  the  foot  is  more  convex  than  normal  while  the  sole  of  the  foot 


524  THE    EXTREMITIES. 

is  flattened.  One  can  see  and  feel  the  displaced  upper  ends  of  the  meta- 
tarsals on  the  dorsum  of  the  foot.  The  foot  is  shortened  and  the  toes 
point  inward.  Dislocations  of  the  individual  metatarsal  bones  are  much 
rarer.  The  mJddle  ones  are  displaced  upward  and  the  first  and  fifth 
inward  and  outward  respecti\'ely. 


Fig.  335. — Compression  Fracture  of  Os  Calcis.  Following  Fall  upon  the  Feet  prom  a  Height  of 

Forty  Feet. 
a,   .\stragalus;     c,   c,    c,    fragments  of  os   calcis. 


Dislocations  of  Die  Toes. — These  occur  most  often  in  the  great  toe 
after  forcible  dorsal  flexion.  The  dislocation  may  be  complete  or  in- 
complete. In  the  former  case  the  proximal  end  of  the  first  phalanx  is 
prominent  on  the  dorsum  of  the  foot,  and  on  the  sole  of  the  foot  the  head 
of  the  metatarsal  bone  projects. 


SHOCK    AND    HEMORRHAGE.  525 

Complications  of  Injuries, 
shock  and  hemorrhage. 

It  is  of  the  greatest  importance  to  be  able  to  recognize  the  presence  of 
one  or  both  of  these  comphcations  chnicahy  in  order  that  the  case  may 
be  intelhgently  treated. 

The  symptoms  of  hemorrhage  into  closed  cavities,  hke  the  cranium, 
pleural,  pericardial,  and  peritoneal  cavities,  have  already  been  referred 


Fio.  356. — View  of  Ankles  from  Behind. 
The  illustralion  shows  the  normal  depressions  to  either  side  of  the  tendo  Achillis,  and  between  the  lower 
border  of  the  malleoli  and  the  os  calcis.  These  depressions  are  all  partially  or  entirely  obliterated  in  sprains 
or  in  fractures  of  the  tarsal  bones.  (See  text.)  /,  Inner  malleolus;  E,  outer  malleolus;  A  ,  location  of  bursa 
between  the  point  of  insertion  of  tendo  Achillis  and  os  calcis,  referred  to  as  a  painful  spot  in  inflammations 
of  the  bursa  (achillodynia). 

to.  They  do  not  differ  in  their  constitutional  signs  from  those  following 
an  injury  of  the  extremities.  In  the  latter,  however,  the  symptoms  of 
shock  and  hemorrhage  often  coexist,  es])eciall_\-  after  severe  crushing 
injuries,  so  that  a  differentiation  is  almost  impossible. 

The  most  characteristic  signs  0}  hemorrhage  arc  the  following: 
I.  Marked  pallor  of  the  skin  and  of  the  visible  mucous  membranes, 
such  as  the  hps,  gums,  tongue,  and  conjunctiva'.     The  latter  is  best 
seen  when  the  lower  cvelid  is  everted. 


526 


THE    EXTREMITIES. 


2.  The  pulse  is  soft  and  rapid.  It  lacks  its  normal  tone  and  the 
tension  becomes  less  and  less  as  the  hemorrhage  increases.  If  the  prim- 
ary loss  has  been  very  great  the  peripheral  pulse  may  from  the  first  be 
scarcely  palpable  and  the  heart-beats  are  very  feeble. 

3.  The  pupils  are  widely  dilated  and  there  is  no  response  to  light. 

4.  The  mental  condition  varies.  If  the  primary  loss  of  blood  has 
been  moderate  or  even  excessive,  but  there  has  been  no  further 
hemorrhage,  the  patient  is  apathetic,  responds  very  slowly  to  external 
stimuH  or  to  questions,  or  may  even  be  in  a  deep  stupor.  If  the  hemor- 
rhage continues  this  condition  becomes  one  of  deep  coma,  followed  by 

convulsions  and  death.  In  some 
cases  each  fresh  hemorrhage  is  ac- 
companied by  attacks  of  syncope  or 
fainting  from  which  the  patient  slowly 
recovers,  but  remains  in  a  feeble  con- 
dition. 

5.  Dyspnea  is  a  very  marked 
symptom,  especially  if  the  loss  of 
blood  is  a  progressive  one.  This  is 
often  accompanied  by  great  restless- 
ness (even  though  the  sensorium  is 
benumbed)  and  by  constant  thirst. 

6.  There  is  usually  a  marked  fall 
in  blood-pressure. 

The  most  characteristic  signs  of 
shock  are: 

I.  The  skin  is  cold,  pale,  and  may 

be  covered  with  perspiration.     The 

temperature  is  subnormal.     There  is 

pallor  of  the  skin  and  visible  mucous 

membranes,  but  this  is  less  marked  than  in  cases  of  hemorrhage.     The 

pallor  is  often  accompanied  by  more  or  less  cyanosis. 

2.  The  pulse  is  very  weak,  rapid,  and  often  irregular  or  intermittent. 

3.  The  pupils  are  widely  dilated. 

4.  The  mental  hebetude  is  even  more  marked  than  in  hemorrhage, 
and  it  is  difficult  to  arouse  the  patient.  They  are  very  apathetic  and 
muscular  relaxation  is  extreme.  Less  often  there  is  slight  delirium 
and  great  restlessness. 

From  the  above  it  will  be  seen  that  the  more  important  symptoms  of 
shock  and  hemorrhage  bear  a  great  resemblance  to  each  other.  In 
many  cases,  especially  of  extensive  wounds  or  crushing  injuries  of  the 


Fig.  357. 
OutKnes  of  normal  ankle  showii  on  the  right, 
and  of  characteristic  obliteration  of  depressions 
on  either  side  of  the  tendo  Achillis  which  occurs 
in  sev'ere  sprains  of  the  ankle-joint,  with  or  with- 
out fracture  of  either  bone  of  the  leg,  or  frac- 
tures of  the  tarsal  bone. 


SHOCK    AND   HEMORRHAGE. 


527 


extremities,  they  coexist.     In  such  cases  the  persistence  of  mental  torpor, 
rapid  weak  pulse,  shallow  breathing — even  though  the  source  of  the 
hemorrhage  has  been  checked  and  the  loss  partially  compensated  for  by 
transfusions,  etc. — should  lead  one  to  suspect  the  coexistence  of  shock. 
There  are  apparently  two  classes  of  cases  of  shock — (a)  the  erethis- 


FiG.  358. — Compression  Fractures  of  the  Astragalus  and  Os  Calcis,  Foi.i.owing  a  Fall  of  Eighty 

Feet. 

Outline  of  fibula;  T   tibia;  a,  posterior  fragment  of  fractured  astragalus.     The  various  letters  c  represent 

the  comminuted  fragments  of  the  fractured  os  calcis. 


tic,  and  {b)  the  ordinary  or  tor])id  form.  In  llic  former  the  restless- 
ness, pallor,  etc.,  can  scarcely  be  distinguished  from  that  of  hemorrhage. 
In  the  torpid  or  apathetic  form,  the  mental  condition  is  one  of  more 
marked  stupor,  and  the  muscular  relaxation  and  weakness  are  more 
pronounced  symptoms. 

In  some  cases  the  symptoms  of  shock  pass  over  into  those  of  septic 


528 


THE   EXTREMITIES. 


infection.  The  pulse-tension  is  then  increased,  dehrium  becomes  a  more 
marked  symptom,  and  the  pulse-rate  rises  rapidly.  The  marked  increase 
in  temperature  as  taken  per  rectum  and  the  presence  of  leukocytosis 
serve  to  distinguish  it  from  shock.  Fat  embolism  has  already  been 
referred  to  (page  443)  as  a  complication  of  fractures,  and  may  simulate 
the  symptoms  of  shock  or  be  obscured,  at  first,  by  those  of  the  latter  con- 
dition. 

Cyanosis  is  a  more  constant  symptom  of  fat  embohsm  than  of  shock. 
The  respiration  is  also  stertorous  and  rapid,  ^Yhile  it  is  shallow  and  slower 


Fig.  359. — Method  of  Examination  for  Fracture  of  tece  Metatarsal  Bone. 
The  foot  is  grasped  between  the  fingers  of  the  two  hands  in  order  to  determine  the  false  point  of  motion  and 

crepitus. 

in  shock.     The  diagnosis  of  fat  embolism  can  be  confirmed  by  finding 
free  fat  in  the  urine. 

The  pulmonary  symptoms  are  usually  more  marked  in  fat  embolism 
than  in  shock.  They  are  either  great  dyspnea  and  asphyxia  or  those  of 
pulmonary  edema  with  expectoration  of  frothy,  blood-stained  mucus. 
In  some  cases  cerebral  symptoms  predominate. 


TRAUMATIC  DELIRIUM  AND  DELIRIUM  TREMENS. 
In  addition  to  the  delirium  often  accompanying  head  injuries,  a  dis- 
tinct form  exists  which  follows  both  injuries  and  operations  in  those  not 


INFECTIVE    COMPLICATIONS    OF    WOUNDS.  529 

admitted  to  be  alcoholics,  and  has  been  termed  traumatic  delirium.  It 
is  especially  frecjuent  after  injuries  of  the  extremities  in  the  young  and 
in  the  aged,  and  after  extensive  burns  at  all  ages.  If  it  exists  more  than 
a  few  hours  after  an  injur}^,  other  causes  should  be  sought  for,  such  as 
great  loss  of  blood,  septic  infection,  suppression  of  urine,  acetonemia, 
iodoform  absorption,  or  senile  atrophy  of  the  brain  in  the  aged.  If  these 
can  be  excluded,  the  case  must  be  considered  as  one  of  true  nervous 
traumatic  dehrium.  The  latter  is  of  a  low,  muttering  character  with- 
out fever.     Its  etiology  is  not  quite  clear. 

The  recognition  of  dehrium  tremens  is  not  difficult.  It  most  often 
foUows  fractures.  The  condition  rarely  begins  suddenly  and  then  only 
after  a  severe  loss  of  blood.  ]Most  frequently  the  onset  is  gradual  in 
chronic  alcoholics.  The  patients  are  at  first  restless,  even  very  talkative, 
rarely  depressed.  They  complain  of  not  being  able  to  sleep,  and  soon 
begin  to  show  marked  tremors  and  become  delirious.  There  is  now  com- 
plete insomnia,  constant  low,  muttering  delirium,  or  loud  outcries. 
Efforts  are  made  to  get  out  of  bed,  accompanied  by  cries  and  marked 
tremor.  Hallucinations  and  illusions  are  constant,  and  there  is  incessant 
muscular  activity  accompanied  by  an  increase  in  the  pulse-rate,  cyanosis, 
etc.,  until  death  ensues,  unless  the  treatment  has  succeeded  in  controlKng 
the  disease.  If  high  fever  is  present  one  must  suspect  the  coexistence  of 
septic  infection  or  of  a  pneumonia,  which  may  end  by  crisis. 


INFECTIVE  CORIPLICATIONS  OF  WOUNDS. 

The  various  tissues  of  the  extremities  are  subject  to  the  same  varieties 
of  infection  as  have  been  referred  to  in  the  head,  neck,  thorax,  and  abdo- 
men. The  chief  differences  are:  (c)  the  extremities  are  more  frequently 
the  seat  of  injuries  than  are  other  portions  of  the  body;  {h)  the  anatomic 
conditions  are  such  that  the  spread  of  infection  is  greatly  favored. 
This  is  especially  true  of  infection  in  the  upper  extremity. 

Infections  of  the  extremities  have  two  modes  of  origin:  {a)  from 
without  inward,  as  occurs  after  operations  or  injuries,  or  {h)  the  limb  is 
the  seat  of  a  local  process  whith  results  from  some  systematic  infection. 
The  second  mode  of  origin  is  far  less  frequent  than  the  first-named. 

It  is  important  to  remember  from  a  diagnostic  standpoint  that  the 
clinical  course  of  an  infection  varies  greatly. 

1.  It  may  remain  local  throughout  its  course. 

2.  It  may  become  general,  as,  for  example,  hydrophobia,  glanders, 
anthrax,  emphysematous  cellulitis,  mahgnant  edema,  and  the  more  viru- 
lent forms  of  streptococcus  and  staphylococcus,  or  bacillus  pyocyaneus 

34 


530  THE   EXTREMITIES. 

infections.  In  this  second  group  the  organisms  may  give  rise  to  a  ver}^ 
characteristic  cHnical  picture,  or  the  general  infection  or  absorption  of 
toxins  (as  the  case  may  be)  present  the  features  of  a  sapremia,  septi- 
cemia, or  septicopyemia. 

A  comparatively  insignificant  local  focus  may  give  rise  to  the  most 
grave  forms  of  general  infection,  so  that  a  thorough  knowledge  of  the 
chief  diagnostic  features  of  both  local  and  general  infections  is 
essential. 

Local  Infections  in  the  Upper  and  Lower  Extremities. — The 
organisms  most  frequently  concerned  in  these  are  (a)  the  staphylococci 
and  streptococci.  Among  the  other  rarer  bacterial  agents  are  (b)  the 
bacillus  pyocyaneus,  streptococcus  eri-sipelatis,  bacillus  of  malignant 
edema,  bacillus  aerogenes  capsulatus,  pneumococcus,  colon  bacillus, 
gonococcus,  influenza  bacillus,  bacillus  of  anthrax,  and  typhoid  bacillus. 

Of  the  second  class  just  enumerated,  infections  with  the  organisms 
of  erysipelas,  malignant  edema,  and  the  bacillus  aerogenes  capsulatus 
result  in  such  typical  clinical  pictures  that  they  will  be  described  sepa- 
rately. The  diagnosis  of  whether  an  infection  is  due  to  the  other  organ- 
isms mentioned  in  this  second  group  can  only  be  made  if  (a)  a  primary 
focus  exists  elsewhere  and  (&)  the  organisms  are  found  in  the  pus  either 
by  microscopic  examination  or  by  bacteriologic  tests.  In  the  case  of 
infection  with  the  bacillus  pyocyaneus,  it  may  be  recognized  by  the 
bluish  or  bluish-green  color  of  the  pus  and  a  peculiar  sour  odor. 

Staphylococcus  and  streptococcus  infections  are  greatly  influenced 
by  anatomic  conditions  and  by  their  own  special  characteristics.  In 
regard  to  the  latter  it  may  be  said  that,  in  a  general  way,  staphylococcus 
infection  is  usually  more  circumscribed,  does  not  spread  as  rapidly,  and 
produces  a  thicker  pus  than  is  the  case  with  the  streptococcus  pyogenes. 
The  latter  is,  as  a  rule,  far  more  virulent,  extends  along  the  surface  (es- 
pecially by  way  of  the  lymphatics)  much  more  rapidly,  and  produces,  if 
in  pure  culture,  a  thin  turbid  serum,  which  to  the  uninitiated  is  not  recog- 
nizable as  pus. 

A  staphylococcus  infection  in  the  extremities  is  much  more  apt  to 
spread  along  tendon-sheaths  and  intermuscular  septa  than  is,  as  a  rule, 
the  case  with  the  streptococcus.  In  the  upper  extremity  infection  may 
occur  either  through  a  wound  or  through  a  hair-folhcle.  The  wound 
may  be  an  extensive  one,  or  even  microscopic  in  size. 

A  reference  to  Fig.  360  will  show  the  chief  anatomic  points  and  modes 
of  transmission  of  infection  from  the  fingers  to  the  forearm,  etc. 

The  chnical  forms  are:  (a)  In  the  epidermis;  (b)  in  the  subcuta- 
neous connective  tissue;  (c)  along  the  tendon-sheaths;  (d)  around  the 


INFECTIVE    COMPLICATIONS    OF   WOUNDS. 


531 


matrix  and  beneath  the  nail,  and  (e)  between  the  muscles  of  the  hand, 
forearm,  and  arm. 

(a)  Epidermal  Infection. — This  can  be  recognized  chnically  by  the 
presence  of  blisters  or  bullae  which  contain  pus.  If  the  entire  epidermal 
covering  is   removed,  the 

deeply  injected  upper  lay- 
ers of  the  rete  malpighii 
are  exposed. 

(b)  Infection  of  the  Cu- 
taneous and  Subcutaneous 
Tissues  {Cellulitis  of  Fin- 
ger or  Hand). — This  not 
infrequently  follows  an 
insignificant  punctured 
wound  whose  possibihty 
of  causing  infection  may 
have  entirely  escaped  the 
patient's  memory. 

On  account  of  the  ana- 
tomic fact  that  the  connec- 
tive-tissue fibers  on  the 
flexor  surface  of  the  fingers 
run  at  right  angles  to  the 
bone  the  infection  is  more 
frequently  carried  directly 
to  the  periosteum  or  the 
tendon-sheath  than  is  the 
case  on  the  dorsum.  On 
the  latter  surface  it  is 
more  likely  to  spread  along 
the  lymphatics  in  an  up- 
ward direction,  or  remain 
localized  in  the  form  of  a 
furuncle  in  the  subcuta- 
neous tissue.  The  possibility  of  such  insignificant  foci  on  the  dorsum  of 
the  fingers  or  hand  being  the  starting-point  of  a  lymphangitis  or  cubital 
or  axillary  lymphadenitis  must  be  constantly  borne  in  mind.  The  case 
may  be  seen  at  a  time  when  the  primary  focus  has  healed  and  the  most 
prominent  symptom  is  a  suppurative  cubital  or  axillary  lymphadenitis. 

If  the  pus  is  present  in  the  subcutaneous  tissue  the  skin  of  the  finger, 
hand,  or  forearm  is  indurated,  very  tender  to  the  touch,  feels  hot,  red- 


FiG.  360. — Relations  of  Flexor  Tendon-sheaths  to  Hand 
AND  Forearm. 
I  Flexor  tendon-sheath  of  little  finger  extending  through 
annular  Ugament  to  lower  third  of  forearm;  2,  flexor  tendon- 
sheath  of  thumb  extending  to  lower  third  of  forearm,  i  and  2 
often  communicate.  3,  Flexor  tendon-sheaths  of  index-,  middle, 
and  ring-fingers,  terminating  at  middle  of  palm  of  hand,  and 
beginning  again  just  distal  to  the  wrist-joint. 


532  THE   EXTREMITIES. 

dened,  and  there  is  a  constant  throbbing  pain.  If  comphcated  by  a 
lymphangitis  a  red  streak  can  be  seen  spreading  over  the  hand  and 
forearm  to  the  cubital  or  axillary  lymph-nodes. 

If  the  infection  has  extended  through  the  periosteum  of  the  phalanges 
a  so-called  felon  results.  This  can  be  recognized  before  incision  by  the 
intensity  of  the  pain,  which  is  far  greater  than  in  the  other  forms.  If 
the  felon  or,  as  it  can  be  more  correctly  termed,  suppurative  periostitis 
of  a  phalanx  has  been  incised  or  the  pus  has  been  spontaneously  evac- 
uated a  sinus  hned  with  exuberant  purulent  granulations  remains, 
which  may  persist  for  months  until  the  sequestrum  has  been  removed 
or  discharged  spontaneously. 

If  the  infection  is  in  the  palm  of  the  hand,  the  swelling  of  the  dorsum 
is  often  so  great  that  it  would  appear  as  though  the  infection  were  on 
this  side. 

(c)  Along  the  Tendon-sheaths. — Infection,  as  a  rule,  only  spreads  along 
the  flexor  sheaths,  on  account  of  the  anatomic  fact  that  the  latter  extend 
almost  to  the  end  of  the  fingers  on  the  palmar  surface,  while  on  the  dor- 
sum the  extensor  sheaths  terminate  at  the  middle  of  the  back  of  the  hand. 

In  virulent  cases  the  infection  may  spread  in  twenty-four  hours  from 
the  finger-tip  to  the  forearm.  This  condition  can  be  recognized  from 
the  fact  that  the  entire  finger  is  swollen  on  its  flexor  surface  and  the  inter- 
phalangeal  folds  are  effaced.  The  palm  of  the  hand  along  the  course  of 
the  tendon  is  tender  and  swollen  and  examination  of  the  wrist  will  reveal 
an  area  of  redness  and  tenderness  extending  to  the  beginning  of  the  fore- 
arm. Such  an  involvement  of  the  tendon-sheaths  also  causes  marked 
swelhng  of  the  dorsum  of  the  hand  and  a  rise  in  the  patient's  temperature. 

(d)  Ungual  and  Subungual  Infection. — The  first  effect  of  an  infection 
is  to  cause  pain  referred  to  the  matrix  of  the  nail.  Considerable  pus 
may  accumulate  beneath  the  nail,  so  that  pressure  upon  the  nail  at  its 
matrix  will  show  a  ballottement  similar  to  that  of  a  patella  floating  on 
fl[uid  in  the  knee.  If  the  matrix  is  completely  detached,  it  can  often  be 
separated  from  its  bed  by  pushing  back  the  fold  of  skin  at  its  base.  Not 
infrequently  a  sinus  or  ulcer  will  form,  as  is  the  case  of  a  felon  covered 
with  exuberant  granulations,  which  wifl  persist  for  weeks  or  even  months 
until  the  dead  nail  is  removed  (Fig.  361) .  The  author  has  seen  a  number  of 
such  cases  in  which  a  diagnosis  of  chancre,  etc.,  had  been  wrongly  made. 

(e)  Between  the  Muscles  and  Tendons  of  the  Forearm  and  Arm. — • 
This  has  been  correctly  termed  an  intermuscular  phlegmon.  It  may  be 
due  to  transmission  of  infection  from  the  hand  or  be  the  result  of  an  in- 
fected wound  or  other  focus  of  suppuration. 

Not  infrequently  an  infection  of  the  subcutaneous  connective  tissue 


Fig.  361. — Ulcer  of  Toe,  Which  was  the  External  Opening  of  a  Sinus  Leading 
TO  A  Dead  Nail,  the  Result  of  a  Paronychia  of  a  Suppurative  Arthritis  of  the 
Distal  Interphalangeal  Joint. 


INFECTIVE    COMPLICATIONS    OF    WOUNDS. 


D0v5 


coexists.  Unless  attention  is  paid  to  the  fact  that  free  incision  of  the 
more  superficial  infection  produces  no  cliange  in  the  symptoms  of  septic 
intoxication  (fever,  rapid  pulse,  etc.)  the  deeper  phlegmon  is  often  over- 
looked until  too  late.  The  latter  causes  considerable  swelhng  and  ten- 
derness of  the  forearm  and  arm  proper.  This  is  most  marked  around 
the  wrist-  and  elbow-joints. 

Pain  is  not  very  marked,  the  most  prominent  symptoms  being  the 
swelling,  tenderness,  and  persistence  of  fever.  If  there  is  much  accom- 
panying involvement  of  the  cutaneous  and  subcutaneous  tissues,  the 
skin  is  of  a  deep  red  color,  indurated,  and  the  tenderness  on  pressure  is 
more  marked.     It  is  often  necessary  to  distinguish  this  condition  (inter- 


FiG.  362. — Phlegmon  of  Arm  Causing  Enormous  Swelling,  Most  Marked  in  Close  Proximity 
TO  THE  Elbow-joint,  due  to  the  Lodgment  of  a  Septic  Embolus,  Secondary  to  a  Gangrene 
OF  the  Lung. 

muscular  phlegmon)  from  erysipelas,  and  the  same  may  be  true  in  the 
case  of  extensive  diffuse  phlegmons  in  the  lower  extremity.  In  the  case 
of  erysipelas  the  infiltration  of  the  skin  is  firmer,  has  a  glazed  appearance, 
and  the  red  color  is  of  a  darker  hue_  and  is  less  diffuse  than  in  phlegmon. 
Another  point  of  difference  is  that  in  erysipelas  the  line  of  demarcation 
between  infected  and  non-infected  skin  is  quite  sharp.  The  edge  is  often 
raised  above  the  level  of  the  surrounding  skin  and  is  irregular.  In  a 
phlegmon  the  edge  passes  imperceptibly  into  that  of  the  surrounding  skin 
and  is  not  elevated  or  irregular. 

Infections  of  the  interphalangeal  and  mctacarpo-phalangeal  joints  do 
not  differ  from  those  of  joints  elsewhere  and  will  be  considered  in  the 
diagnosis  of  purulent  arthritis  in  general. 


554  THE   EXTREMITIES. 

Infective  Processes  in  the  Lower  Extremities. — Infection  with 

the  ordinar}'  pyogenic  organism  is  far  less  frequent  than  in  the  upper 
extremities.  They  may  originate  (a)  from  an  ingrown  toe-nail  or  an 
abrasion  of  the  foot  -^-ith  lymphangitis  extending  to  the  inguinal  lymph- 
nodes  as  a  red  streak;  (&)  as  a  comphcation  of  compound  fractures;  (c) 
from  an  inflamed  varicose  vein  or  an  infected  ulcer  of  the  leg;  {d)  sec- 
ondare' to  an  osteomyehtis,  usuaUy  of  the  tibia  or  femur.  Of  the  above 
atria  of  infection,  the  first-named  group  is  the  most  frequent.  The  ar- 
rancrement  of  the  tendon-sheaths  of  the  flexor  and  extensor  muscles  of  the 

o 

foot  and  toes  is  such  that  infection  rarely  travels  upward  through  these 
channels.  Infection  in  the  lower  extremities  is  much  more  apt  to  be 
transmitted  along  the  lymphatics  and  in  the  loose-meshed  subcutaneous 
connective  tissue  than  is  the  case  in  the  arm.  In  children  and  young 
adults,  the  rapidity  with  which  infection  spreads  is  much  greater  than  in 
later  hfe. 

Attention  has  already  been  called  to  the  fact  that  suppuration  of  the 
cubital  and  axiUar}^  lymph-nodes  may  not  occur  until  two  to  three  weeks 
after  the  primary  focus  was  noticed.  The  same  is  true  of  the  lower 
extremities,  especially  in  children.  A  case  may  present  itself  for  diag- 
nosis with  inflamed  lymph-nodes  in  the  subinguinal  region  (Scarpa's 
triangle)  in  which  an  infected  abrasion  or  an  ingroeem  toe-nail  was  either 
not  observed  or  had  already  healed. 

Another  diagnostic  point  not  to  be  forgotten  in  connection  with  in- 
fection in  the  lower  extremities  is  the  fact  that  the  pus  may  extend  into 
the  deep  lymph-nodes  lying  within  the  pelvis  (deep  ihac  group)  from  the 
external  (superficial  inguinal)  set  and  cause  long-continued  fever  and 
other  septic  phenomena  before  they  are  recognized  by  finding  a  tender 
mass  upon  deep  palpation  of  the  iliac  fossae.  Infection  of  the  prepatellar 
bursa  and  of  the  knee-joint  occurs  far  more  frequently  as  a  comphcation 
of  suppuration  in  the  lower  than  is  the  case  with  similar  bursas  and  joints 
of  the  upper  extremities.  The  diagnosis  of  these  conditions  is  considered 
on  page  566. 

The  diagnosis  of  subungual  and  periungual  suppuration  and  infection 
of  the  interphalangeal  and  metatarso-phalangeal  joints  does  not  dift'er 
from  that  of  the  same  conditions  in  the  upper  extremities.  They  show, 
in  general,  less  of  a  tendency  to  spread.  Ingrown  toe-nail,  which  is  a 
form  of  subungual  infection,  is  readily  recognized  from  the  local  pain, 
redness,  and  the  exuberant  granulations  along  the  side  of  the  nail.  A 
dead  nail,  as  in  the  fingers,  may  cause  a  long-continued  ulceration  of 
the  neighboring  tissue  (Fig.  361). 

Emphysematous  Cellulitis  and  Malignant  Edema. — These  are 


INFECTIVE    COMPLICATIONS    OF   WOUNDS.  535 

rare,  but  yet  frequent  enough  forms  of  infection  of  bullet  wounds,  com- 
pound fractures,  abrasions,  etc.,  to  demand  attention.  In  the  majority 
of  text-books  no  distinction  is  made  between  emphysematous  celMitis 
produced  by  the  bacillus  aerogenes  capsulatus,  and  the  rapidly  spreading 
gangrenous  form  of  infection  due  to  the  bacillus  of  malignant  edema. 
They  both  lead  to  gangrenous  processes  in  an  arm  or  leg  following  one 
of  the  above  classes  of  wounds,  accompanied  by  a  hemorrhagic  exudate 
and  the  development  of  gas  in  the  tissues.  The  conditions  may  be  recog- 
nized (a)  by  the  rapidly  spreading  discoloration,  swollen  condition  of  the 
hmb,  and  early  gangrene;  {b)  by  the  crepitation  on  pressure  when  the 
hmb  is  palpated;  (c)  from  the  foul-smelHng  hemorrhagic  serum  which 
exudes  from  the  wound,  and  (d)  from  the  early  onset  of  marked  septic 
symptoms,  such  as  high  temperature,  rapid  pulse,  dehrium,  and  marked 
leukocytosis.  Death  may  take  place  within  a  few  days  unless  amputa- 
tion be  performed.  The  diagnosis  of  which  organism  is  concerned  should 
be  made  as  early  as  possible  by  making  cover-shp  preparations  of  the 
bloody  serum,  and  cultures  on  anaerobic  media.  If  death  ensues  from 
the  immediate  virulence  of  the  infection,  the  case  may  pursue  a  more 
protracted  typhoid-like  course. 

Erysipelas.— This  form  of  infection,  like  those  due  to  the  ordinary 
pyogenic  organisms,  may  be  a  complication  of  operations,  of  ulcerative 
processes,  of  compound  fractures,  or  any  form  of  injury  of  the  extremities. 
It  occurs  less  frequently  here  than  on  the  face. 

Erysipelas  most  often  begins  with  a  chill  and  a  reddening  of  the  edges 
of  the  wound,  accompanied  by  a  rise  of  temperature.  Within  a  few 
hours  the  skin  around  the  wound  assumes  its  characteristic  appearance, 
from  a  careful  inspection  of  which  the  diagnosis  can  usually  be  made. 
The  edges  of  the  area  of  redness  usually  show  a  sharp  demarcation  from 
the  normal  skin.  The  edge  is  raised  above  the  surrounding  level  and 
of  ten  shows  irregular  prolongations,  giving  it  a  jagged  appearance.  Red 
streaks  can  frequently  be  seen  running  toward  the  regional  lymph-nodes 
from  the  area  of  infection.  They  are  due  to  an  involvement  of  the  lymph- 
vessels  (lymphangitis).  In  many  cases  the  erysipelatous  redness  spreads 
from  day  to  day,  growing  pale  where  the  limb  was  first  involved. 

In  healthy  individuals  the  color  of  the  area  is  of  a  deep  reddish  hue. 
In  those  with  a  tendency  to  venous  congestion  it  has  a  bluish  tint,  while 
in  anemic  or  cachectic  persons  it  is  of  a  light  red  shade.  Over  this  area 
numerous  vesicles  or  even  Ixilla;  arc  found.  The  swelling  of  the  skin  is 
usually  marked,  so  that  the  infected  area  feels  tense,  ghstens,  and  does  not 
pit  on  pressure.  The  following  may  be  mentioned  as  infrequent  local 
complications  in  the  severer  cases:  abscesses  in  the  subcutaneous  tissue. 


536  THE    EXTREMITIES. 

infection  of  tendon-sheaths,  intermuscular  spaces,  and  joints,  as  well  as 
gangrene  of  the  skin.     The  latter  is  most  apt  to  occur  in  the  finger-tips. 

The  general  symptoms  of  erysipelas  are :  (c)  The  presence  of  more  or 
less  fever  of  a  continuous  type.  The  rise  of  temperature  is  less  often 
of  a  distinctly  remittent  type  and  is  accompanied  by  repeated  chiUs. 
(b)  A  rise  of  pulse-rate  accompanies  the  fever,  (c)  Delirium  is  often 
present,  especially  in  elderly  persons  and  in  those  cases  characterized  by 
marked  septic  symptoms  and  high  fever. 

Among  the  complications,  whose  possible  appearance  must  be  con- 
stantly borne  in  mind  during  the  course  of  the  disease,  are  pneumonia, 
ulcerative  endocarditis,  septicemia,  and  less  frequently  pleuritis,  men- 
ingitis, and  nephritis. 

The  dijfereniiation  0}  erysipelas  jrom  a  phlegmon  is  not  difficult,  as  a 
rule.  In  erysipelas  the  skin  is  often  covered  with  blebs,  the  redness  is  of 
a  bright,  gHstening  character,  and  the  border  is  more  or  less  jagged  or 
irregular  and  sharply  marked  off  from  the  healthy  skin.  In  a  streptococ- 
cus phlegmon,  from  which  the  differentiation  must  usually  be  made,  the 
induration  is  more  board-like,  and  the  redness  is  of  a  darker  hue.  In 
addition,  the  skin  does  not  ghsten,  seldom  has  blebs,  and  the  area  of  red- 
ness shows  no  sharp  line  of  demarcation. 

Erysipeloid. — This  is  a  form  of  wound  infection  Avhich  often 
occurs  in  cooks,  butchers,  and  others  who  handle  game,  fish,  and  oysters. 
It  is  usually  found  on  the  fingers  as  a  dark  red  swelhng  with  quite  a  sharp 
border.  It  gradually  extends  from  the  finger  upon  which  it  happens  to 
begin  to  the  remaining  fingers  and  to  the  hand,  as  in  a  true  erysipelas. 
The  disease  lasts  about  three  weeks  and  ceases  spontaneously.  There  is 
but  little  general  disturbance.  Locally  the  patients  complain  of  tinghng 
and  itching. 

The  diagnosis  is  usually  easy  from  (a)  its  location  on  the  fingers  or 
hand;  (b)  the  occupation  of  the  patient;  (c)  the  absence  of  fever; 
(d)  the  bluish  redness  of  the  eruption  and  its  slow  spreading  with  only 
a  minimal  amount  of  infiltration  of  the  skin. 

From  er}'sipelas  it  can  be  difi'erentiated  by  the  absence  of  fever,  its 
slow  spreading,  and  the  fact  that  it  lacks  the  bright  redness,  tension,  and 
glistening  appearance  of  an  erysipelatous  area. 

Sapremia,  Septicemia,  and  Pyemia. — Infection  of  a  wound  either 
sustained  through  injury  or  subsequent  to  an  operation;  by  any  of  the  or- 
ganisms just  referred  to,  may  be  followed  by  one  of  three  groups  of  symp- 
toms.    They  may  also  follow  any  of  the  acute  forms  of  bone  infection. 

Sapremia  means  a  local  infection  with  the  development  of  toxins. 
This  condition  is  present  if  fever  develops  after  the  infliction  of  a  wound, 


INFECTIVE    COMPLICATIONS    OF   WOUNDS.  537 

accompanied  by  other  general  symptoms,  such  as  malaise,  rapid  pulse, 
restlessness,  headache,  and  prostration.  Locally  one  finds  all  of  the 
evidences  of  infection  described  on  page  531.  The  gravity  of  the  initial 
symptoms  varies  according  to  the  amount  of  toxins  absorbed.  Instead 
of  high  fever,  etc.,  one  may  find  rapid  collapse,  coma,  and  death,  or  the 
condition  passes  imperceptibly  into  one  of  septicemia  or  of  septicopyemia. 
If  the  sapremia  is  of  a  moderate  type,  and  due  to  imperfect  drainage  of  a 
wound,  it  is  often  characterized  by  a  regular  evening  rise  of  temperature 
and  a  considerable  degree  of  leukocytosis. 

The  most  important  differential  point  between  sapremia  (septic  tox- 
emia) and  septicemia  (bacteriemia)  is  that  when  thorough  treatment  of 
the  focus  of  infection  has  been  instituted  the  symptoms  of  fever,  etc., 
disappear  in  sapremia,  but  show  no  improvement  in  septicemia. 

In  sapremia  the  signs  of  local  infection  predominate,  while  in  sep- 
ticemia it  is  the  general  symptoms  of  poisoning  which  attract  attention. 

Septicemia. — In  this  form  of  infective  complication  of  wounds  there 
is  a  constant  formation  of  toxins  in  the  blood  itself,  due  to  the  bacteri- 
emia which  exists.  The  eradication  of  the  primary  focus  does  not  cause 
a  termination  of  the  symptoms  as  in  sapremia.  Such  a  step  has  but 
little  influence  upon  the  course  of  either  septicemia  or  the  next  form  to  be 
described,  septicopyemia.  The  chief  diagnostic  features  of  a  progressive 
septicemia  from  local  infection  are  the  following: 

1.  Fever. — Usually  this  is  of  a  continuous  type.  The  occurrence 
of  chills  is  not  characteristic  of  septicemia,  although  it  occurs  at  times. 

2.  Pulse. — This  is  at  first  full,  somewhat  increased,  and  shows  tension. 
As  the  infection  progresses,  it  is  soft,  lacks  tension,  becoming  weaker  and 
more  rapid.  The  rapidity  of  the  pulse  is  in  general  a  good  criterion  of 
the  severity  of  the  infection,  being  140  to  160  in  the  graver  cases. 

3.  Mental  Disturbances. — Headache  and  mental  dullness  are  quite 
common,  but  not  infrequently  unusual  clearness  and  activity  of  the  mind 
continue  throughout  the  greater  part  of  the  illness.  If  mental  stupor 
exists,  it  is  often  accompanied  by  delirium,  and  may  develop  into  deep 
coma. 

4.  Alimentary  Canal. — The  tongue  is  dry  and  covered  with  dirty 
brown  crusts.  The  breath  is  offensive  and  often  has  a  peculiar  sweetish 
odor.  There  is  complete  anorexia,  accompanied  either  by  constipation 
or  by  diarrhea  (septic  enteritis). 

5.  Kidneys. — The  urine  is  scanty,  high-colored,  and  contains  much 
albumin  and  many  hyaline  and  granular  casts. 

6.  Blood.— There  is  usually  a  moderate  degree  of  leukocytosis  (15,000. 
to  20,000).     The  organisms  concerned  in  the  process  may  be  demon- 


538 


TnE   EXTREMITIES. 


strated  in  pure  culture  by  aspirating  blood  from  one  of  the  arm  veins  and 
inoculating  the  blood-serum,  agar,  and  other  media. 

7.  Appearance  of  Wound. — The  wound  secretions  are  often  malodor- 
ous, thinner,  and  smaller  in  quantity.  The  arm  or  leg  may  shov/  local 
evidences  of  an  extensive  progressing  phlegmon  of  the  most  septic  type. 

In  the  most  virulent  forms  of  streptococcus  mahgnant  edema  or 
bacillus  aerogenes  capsulatus  infection  the  local  signs  are  often  the  most 
prominent  feature  of  the  chnical  picture. 

Septicopyemia  or  Pyemia. — -This  condition  is  understood  to  be 
general  infection  resulting  from  the  entrance  into  the  circulation  of  septic 
thrombi  containing  the  ordinary  pus  cocci .     These  infected  thrombi  when 


Fig.  363.— Temperatuke-chart  in  a  Case  of  Pyemia  with  Muscular  Locaiizations. 
*  indicates  a  chill.     The  fall  of  temperature  was  frequently  due  to  the  use  of  the  cold  pack  ("  International 

Text -book  of  Surgery")- 


carried  to  distant  points  form  independent  centers  of  suppuration.  In 
the  extremities  such  a  pyemia  or,  to  use  a  better  term,  septicopyemia  may 
arise  (a)  from  an  infected  wound  of  the  skin  or  deeper  structures,  (b) 
from  an  osteomyelitis,  (c)  from  a  septic  thrombophlebitis,  e.  g.,  of  a  vari- 
cose vein. 

The  chief  features  of  the  disease  as  compared  with  septicemia  are 
the  occurrence  of  chills,  and  of  an  irregular,  more  remittent  type  of  tem- 
perature. Accompanying  these  general  symptoms  are  the  local  ones  due 
to  the  deposit  of  the  infected  thrombi  in  the  lungs,  endocardium,  hver, 
spleen,  kidneys,  skin,  and  bones.  These  symptoms  may  appear  at  any 
period  in  the  course  of  a  wound.  The  disease  may  pursue  a  ver}-  acute, 
a  subacute,  or  a  chronic  course,  the  latter  lasting  for  years. 


INFECTIVE   COMPLICATIONS   OF   WOUNDS.  539 

The  chief  diagnostic  features  of  septicopyemia  are  the  following: 

1.  Fever. — The  onset  is  usually  with  a  chill,  followed  by  a  rise  of  tem- 
perature to  103°  to  105°  F.  and  a  profuse  sweat. 

This  triad,  viz.,  chill,  fever,  and  sweat,  is  repeated  at  intervals,  either 
daily  or  every  other  day.  In  the  intervals  there  may  be  a  slight  rise  of 
temperature.  In  some  cases  chills  either  do  not  accompany  every  rise 
of  temperature  or  are  entirely  absent.  If  the  latter  is  the  case,  there  is 
persistence  of  the  remittent  type  of  fever.  The  rise  of  temperature  may 
occur  at  any  time  of  day  and  even  two  or  three  times  in  twenty-four 
hours.  It  is  this  irregularity  which  serves,  with  the  absence  of  Plas- 
modia in  the  blood,  to  distinguish  it  from  malaria. 

2.  Pulse. — If  the  pyemia  occurs  in  a  previously  healthy  individual 
the  pulse  is  full  and  strong  and  rises  to  120  during  the  fever,  but  may  sink 
to  normal  in  the  interval.  In  the  majority  of  cases  the  pulse  remains  high 
throughout  the  disease. 

3.  Mental  Condition. — -In  the  most  acute  cases  a  typhoid-like  stupor 
exists,  but  in  the  subacute  and  chronic  forms,  the  mind  is  much  clearer 
than  in  septicemia.  The  patients  are  often  fully  conscious,  anxious, 
and  irritable.  As  they  grow  weaker,  stupor  and  dehrium  set  in  and  ter- 
minate in  coma. 

4.  Alimentary  Canal. — -The  most  prominent  symptoms  are  anorexia, 
nausea,  vomiting,  and  rapid  emaciation.  Jaundice  is  a  very  character- 
istic sign  of  pyemia  and  may  be  accompanied  by  marked  anemia.  Diar- 
rhea is  only  present  in  the  later  stages. 

5.  Kidneys. — Traces  of  albumin  and  casts  are  found  in  the  urine.  In 
general  the  signs  of  the  renal  disturbance  are  less  marked  than  in  sep- 
ticemia. 

6.  Evidences  of  Metastases. — These  are  very  important  to  recognize. 
They  have  been  referred  to  on  page  538.  Pulmonary  metastases  reveal 
themselves  clinically  by  the  presence  of  dyspnea,  cough,  and  blood- 
tinged  sputum.  If  many  abscesses  exist,  the  physical  signs  of  a  lobular 
pneumonia  are  found,  or  evidences  of  a  pleurisy.  Embolic  abscesses  in 
the  spleen  cause  localized  pain  and  enlargement  of  the  organ.  Metas- 
tases in  the  liver  produce,  if  small,  local  peritoneal  friction  sounds  and 
tenderness.  If  larger,  they  cause  increased  dullness  and  swcUing. 
Metastases  in  the  skin,  parotid,  thyroid,  testis,  bones,  and  joints  are 
easily  recognized.  A  metastatic  brain  abscess  is  very  rare  and  can  only 
be  diagnosed  if  it  causes  focal  symptoms. 

7.  Appearance  of  Wound. — The  secretion  is  diminished,  the  granula- 
tions appear  pale,  or  flabby  and  necrotic. 


540  THE   EXTREMITIES. 

8.  Blood. — In  pyemia  there  is  marked  leukocytosis,  while  in  malaria 
and  typhoid  there  are  normal  relations  or  leukopenia. 

In  the  differential  diagnosis  of  pyemia  and  septicemia  from  other 
affections  one  must  remember  the  following : 

Acute  suppurative  osteomyelitis. 

Acute  septicopyemia  from  gonorrhea. 

Typhoid  fever. 

Ulcerative  endocarditis. 

Malaria. 

Acute  lymphatic  leukemia. 

Acute  Hodgkin's  disease. 

Pyelitis,  pyelonephritis,  and  perinephritic  abscess. 

Septic  pharyngitis. 

The  profound  anemia  and  the  intermittent  fever  sometimes  seen  in 
rapidly  growing  carcinoma. 

Tetanus. — This  complication  of  accidental  wounds  occurs  far  less 
frequently  at  the  present  time  than  in  the  preantiseptic  era.  It  most  com- 
monly follows  wounds  of  the  hands  and  feet,  especially  those  in  which 
the  wound  of  entrance  in  the  skin  is  comparatively  small  and  closes  at  an 
early  period,  thus  permitting  the  anaerobic  tetanus  germ  to  multiply  in  a 
closed  cavity. 

The  possibihty  of  symptoms  of  tetanus  developiDg  must  always  be 
borne  in  mind  in  punctured  or  blank  cartridge  wounds,  in  crushing 
injuries  of  the  extremities,  and  in  compound  fracture,  whenever  there  is 
any  likelihood  of  street,  garden,  or  stable  dirt  having  been  carried  into 
the  wound. 

Tetanus  may  appear  clinically  in  several  forms,  viz. :  (a)  A  very 
acute  form,  in  which  the  sym.ptoms  appear  during  the  first  eight  days  and 
the  patients  die  within  twenty-four  to  forty-eight  hours  after  onset  of  the 
tetanus  symptoms.  This  class  embraces  about  33  per  cent,  of  the  cases. 
(6)  The  typical  form,  in  which  the  first  symptom  appears  between  the 
eighth  and  fifteenth  days  after  reception  of  the  injury.  About  45  per 
cent,  of  the  cases  belong  in  this  group,  (c)  The  subacute  or  chronic  form, 
in  which  the  first  sign  (lockjaw)  appears  in  the  third  or  fourth  week  after 
the  injur}'.     This  form  embraces  the  remaining  22  per  cent,  of  the  cases. 

In  spite  of  the  variation  in  the  time  of  onset  and  intensity  of  the  in- 
dividual symptoms  in  these  three  groups  there  are  certain  constant  signs 
from  which  a  positive  diagnosis  can  be  made.     They  are : 

I.  A  tonic  spasm  of  the  muscles  of  mastication,  known  as  trismus,  so 
that  the  patient  is  unable  to  open  the  mouth,  a  symptom  so  prominent  that 
the  disease  is  called  by  the  laity  lockjaw.     This  symptom  is  gradual  in  its 


INFECTIVE    COMPLICATIONS    OF   WOUNDS.  54I 

development.  The  patient  is  at  first  able  to  open  and  close  the  mouth, 
but  not  fully.  This  lack  of  control  of  the  voluntary  muscles,  due  to  their 
spasmodic  contraction,  spreads  to  the  muscles  of  the  back  of  the  neck,  so 
that  the  neck  cannot  be  flexed.  The  rigidity  soon  extends  to  the  back  and 
abdominal  muscles.  These  become  very  hard  from  the  tetanic  contrac- 
tion, almost  board-like.  The  trunk  becomes  overextended  through  the 
spasm  of  the  back  muscles,  so  that  the  patient's  weight  rests  upon  the 
head  and  heels,  a  position  called  opisthotonos.  When  the  spasm  affects 
the  muscles  of  the  tongue,  pharynx,  larynx,  and  those  of  respiration,  the 
speech  becomes  indistinct,  there  is  marked  dyspnea,  and  asphyxia  may 
occur  from  spasm  of  the  glottis. 

2.  The  second  symptom  of  tetanus,  viz.,  increased  reflex  irritability 
and  convulsions  of  a  tonic  and  clonic  character,  appears  soon  after  the 
trismus  in  those  cases  in  which  death  does  not  occur,  as  in  acute  tetanus,  in 
twenty-four  to  forty-eight  hours  after  onset  of  the  first  symptom.  These 
spasms  vary  in  duration,  and  affect  all  of  the  rigidly  contracted  muscles. 
Every  irritation,  such  as  a  draft  or  touching  the  patient,  excites  a  con- 
vulsion. 

3.  The  temperature  is  high,  as  a  rule,  but  there  may  be  Httle  or  no 
elevation.  There  is  a  special  class  of  cases,  called  head  or  cephalic 
tetanus,  which  follow  wounds  of  the  head,  especially  those  around  the 
eye  or  of  the  cranial  nerves.  The  most  prominent  symptoms  of  this 
form  are  the  appearance  of  spasms  of  the  muscles  of  deglutition,  and 
a  paralysis  of  the  facial  muscles  on  the  side  of  the  injury,  in  addition  to 
trismus  or  lockjaw.  To  this  form  of  tetanus  the  name  of  tetanus  hydro- 
phobicus  still  clings,  on  account  of  its  resemblance  to  true  hydrophobia. 

Differential  Diagnosis  of  Tetanus. — (a)  In  strychnin  poisoning  the 
rigidity  does  not  persist  in  the  intervals  between  convulsions,  and  the  jaw 
muscles, are  not  the  first  ones  affected,  as  is  almost  invariably  the  case  in 
tetanus.  The  muscles  of  mastication  may  not  be  involved  at  all  in 
strychnin  poisoning,  (b)  In  tetany  the  hands  are  held  in  a  pecuhar 
position,  the  wrists  being  flexed  and  the  fingers  extended  at  the  interpha- 
langeal,  but  flexed  at  the  metacarpo-phalangeal  joints.  The  tonic 
spasms  occur  at  regular  intervals,  involve  the  extremities  chiefly,  and  there 
are  no  general  convulsions.  Tapping  upon  the  facial  muscles  or  pres- 
sure upon  the  bend  of  the  elbow  or  at  the  Ixick  of  the  knee  will  often 
cause  the  spasm  to  appear,  (c)  In  so-called  symptomatic  lockjaw  or 
trismus,  there  is  inability  to  open  the  mouth,  due  to  reflex  contraction  of 
the  masseter  muscles.  There  is  no  liislory  of  a  wound,  no  general 
rigidity,  or  spasms,  or  rise  of  temperature.  An  examination  of  the  mouth 
will  soon  enable  a  correct  diagnosis  to  be  made.     This  reflex  trismus  is' 


542  THE   EXTREMITIES. 

often  due  to  a  stomatitis,  either  due  to  neglect  of  cleanliness,  to  the  use 
of  mercury,  or  to  the  irritation  due  to  the  eruption  of  a  wisdom-tooth. 

Hydrophobia. — This  disease  occurs  rarely  as  a  complication  of 
wounds  of  the  face  and  extremities,  but  its  early  recognition  is  im- 
portant. The  proportion  of  persons  in  whom  the  disease  develops  is 
greater  after  bites  from  wolves  (40  per  cent.)  than  from  dogs  (5  to  15  per 
cent.).  The  average  period  of  incubation  is  four  to  six  weeks,  rarely 
less  (thirteen  to  eighteen  days).  A  period  of  three  to  six,  or  even  from  six 
to  twelve  months  is  rare.  As  in  the  case  of  tetanus  there  are  no  changes 
in  the  wound  which  indicate  a  possible  development  of  the  disease. 
The  wound  appears  red  and  swollen,  and  if  it  has  healed  may  reopen  and 
secrete  a  thin  turbid  pus.  Whenever  possible  after  a  person  has  been 
bitten,  the  animal  should  not  be  killed,  but  kept  under  observation  for  the 
purpose  of  noting  the  development  of  the  symptoms  of  the  disease. 

In  man  the  diagnosis  is  usually  not  made  until  the  appearance  of 
great  irritabihty,  accompanied  by  a  spasm  of  the  muscles  of  the  larynx 
and  those  of  deglutition.  When  the  patient  is  given  some  water  to 
drink,  the  spasmodic  painful  contractions  of  these  muscles  cause  it  to 
be  expelled,  so  that  the  very  sight  of  water  becomes  repulsive. 

The  diagnosis  can  be  made  from :  (a)  The  history  of  the  bite  of  an 
animal,  even  though  it  occurred  weeks  to  months  prior  to  the  onset  of  the 
symptoms.  (&)  A  period  of  mental  depression,  followed  by  one  of  great 
mental  irritabihty  and  anxiety,  (c)  The  onset  of  the  typical  spasm  of  the 
muscles  of  deglutition  whenever  water  is  seen  or  an  attempt  made  to  swal- 
low it.  The  patient  can  still  swallow  soHds  at  first,  but  not  hquids.  (d) 
There  is  increased  reflex  excitabihty,  not  only  of  the  sense  of  sight  for 
water,  but  also  of  other  special  senses,  hke  those  of  smell,  taste,  etc.,  and 
of  the  sexual  organs.  Exhaustion  from  insomnia,  with  rapid  increase  in 
the  pulse  and  respiration,  gradually  appears  and  is  followed  by  death. 
The  only  condition  wliich  needs  to  be  mentioned  in  the  differential 
diagnosis  is  that  of  the  so-called  cephalic  or  ielanus  hydro phohicus 
described  on  page  540,  especially  when  it  follows  a  dog  bite.  In  this, 
there  is  the  history  of  a  wound  of  the  head  or  involving  one  of  the  cranial 
nerves,  accompanied  by  paralysis  of  the  facial  muscles  and  trismus.  In 
both  this  condition  and  true  hydrophobia  there  is  spasm  of  the  muscles 
of  deglutition,  so  that  in  some  cases  the  diagnosis  depends  on  the  trismus 
in  tetanus.  In  rare  cases  the  spasms  of  the  muscles  of  swallowing  may  be 
absent  and  yet  the  case  be  one  of  true  hydrophobia. 

Symptoms  of  difhculty  in  swallowing  may  appear  in  hysterical  per- 
sons some  weeks  after  being  bitten  by  a  dog.  The  clinical  picture  may 
at  first  resemble  that  of  the  genuine  disease,  but  careful  observation  and 


INFECTIVE    COMPLICATIONS    OF   WOUNDS.  543 

a  search  for  other  stigmata  of  hysteria  will  soon  clear  up  the  diag- 
nosis. 

Anthrax. — This  complication  of  wounds  has  been  referred  to  on 
page  530.  It  may  follow  wounds  of  the  face,  hands,  or  arms.  In  ad- 
dition to  this  external  or  cutaneous,  there  are  two  other  rarer  clinical 
forms,  the  alimentary  and  pulmonary.  These  latter  are  fully  de- 
scribed in  the  text-books  on  internal  medicine.  The  cutaneous  form 
appears  either  as  a  pustule  or  as  a  rapidly  spreading  edema.  The  period 
of  incubation  varies  from  two  to  fourteen  days,  and  upon  inquiry  one 
can  usually  obtain  the  history  of  a  wound  received  while  handling  wool, 
sheepskins,  infected  meat,  or  manure. 

In  man  the  diagnosis  of  anthrax  can  usually  be  made  from  the  rapid 
change  in  the  appearance  of  the  wound.  The  site  of  inoculation  begins 
to  swell  and  itch  as  it  does  after  an  insect- bite.  A  bhster  appears  at  the 
apex  of  the  papule  and  the  area  of  induration  around  the  wound  of  inoc- 
ulation rapidly  increases  in  extent,  is  of  a  bluish-red  color,  and  becomes 
covered  with  vesicles.  At  the  center  of  the  area  of  infiltration  a  black, 
gangrenous  slough  appears,  and  this  rapidly  increases  in  size.  The  in- 
fection soon  extends  into  the  adjacent  lymph- vessels  and  regional  lymph- 
nodes.  Lymph-vessel  involvement  causes  red  streaks  of  lymphangitis 
to  appear,  and  lymph-node  infection  is  followed  by  pain  and  swelhng  of 
the  regional  nodes. 

Accompanying  these  local  changes  there  is  high  fever,  severe  head- 
ache, delirium,  rapid  weak  pulse,  and  other  septic  symptoms,  such  as 
diarrhea.  Death  may  occur  quite  early.  The  process  may  remain  a 
local  one,  and  instead  of  a  central  slough  with  a  rapidly  spreading  area 
of  induration,  covered  with  vesicles,  one  may  simply  find  (a)  a  few  ves- 
icles with  moderate  inflammatory  induration,  or  (b)  a  small  gangrenous 
center,  or  (c)  a  pecuhar  edema,  the  so-called  anthrax  edema.  In  the 
latter  the  swelhng  spreads  very  rapidly,  especially  where  the  connective- 
tissue  fibers  are  loosely  arranged  under  the  skin.  The  edematous  area 
is  of  a  dark  bluish  color,  and  may  be  followed  by  extensive  gangrene. 

The  diagnosis  can  usually  be  made  in  all  of  the  above  forms  by  the 
rapidity  of  the  induration  and  sloughing,  the  occujiation  of  the  patient, 
and  finding  the  bacilh  either  in  cover-slip  preparation  or  by  culture  tests. 

Glanders. — This  disease  may  appear  in  such  an  atypical  manner 
and  so  unexpectedly  that  a  short  description  of  its  principal  diagnostic 
features  is  necessary. 

If  the  disease  is  inoculated  through  a  cutaneous  wound  in  man, 
the  wound  soon  ulcerates,  and  there  is  early  swcUing  and  tenderness  of 
the  adjacent  lymph-nodes.     The  local  ulceration  spreads  and  greatly 


544  THE   EXTREMITIES. 

resembles  a  soft  chancre.  Soon  after  this,  red  papules  (farcy  buds) 
appear  in  various  parts  of  the  body,  and  soon  form  abscesses  with  re- 
sultant ulcers  in  the  skin  or  deeper  tissues.  Accompanying  these  signs 
of  a  pyemia  there  is  a  thin  mucopurulent  discharge  from  the  nose. 
Symptoms  of  septicopyemia  appear  in  the  majority  of  cases,  followed  by 
death.  Less  often  the  clinical  picture  is  that  of  articular  rheumatism  or 
typhoid  fever.  In  the  chronic  form  the  same  symptoms,  viz.,  widely 
scattered  areas  of  induration  and  abscess  formation,  appear,  accom- 
panied by  milder  septic  symptoms.  The  diagnosis  can  only  be  made  by 
considering  the  occupation  of  the  patient  and  finding  the  characteristic 
glanders  bacillus  in  the  nasal  discharge  or  in  the  pus. 


Surgical  Diseases  of  the  Extremities, 
affections  of  the  skin  and  subcutaneous  tissues. 

Ulcers. — Ulcers  are  more  frequently  found  on  the  lower  than  the 
upper  extremities.  In  the  diagnosis  of  what  the  cause  and  nature  of  an 
ulcer  might  be,  the  following  must  be  considered  : 

(a)  A  careful  previous  history  should  be  taken  to  ascertain  the 
circumstances  attending  the  first  appearance  of  the  ulcer,  whether  it 
followed  trauma  or  pressure,  or  whether  it  appeared  spontaneously. 
The  duration  of  the  ulcer  and  its  lack  of  tendency  to  heal,  or  its  steady 
growth  in  size,  are  data  of  considerable  value.  The  history  will  also 
throw  light  on  any  constitutional  disease,  such  as  syphihs,  tuberculosis, 
diabetes,  or  spinal- cord  affections. 

(&)  The  examination  of  the  edges  of  the  ulcer  as  to  the  degree  of 
induration;  and  whether  these  edges  are  steep  or  undermined. 

(c)  The  form  of  the  ulcer,  whether  irregular,  serpiginous,  or  reniform. 

(d)  The  floor  of  the  ulcer,  as  to  the  degree  of  slougliing,  and  the  nature 
of  the  granulations  covering  it. 

(e)  The  examination  of  the  hmb  for  varicose  veins,  for  eczema,  for 
evidences  of  arteriosclerosis,  for  syphilitic  periostitis,  etc. 

The  chief  varieties  of  ulceration  which  occur  on  the  skin  of  the  ex- 
tremities, and  their  clinical  characteristics  are : 

I.  Traumatic  Ulcers. — These  occur  in  persons  with  a  lowered  degree 
of  resistance,  or  in  limbs  in  wliich  considerable  venous  stasis  exists.  In 
such  individuals  a  wound  may  heal  so  slowly  that  epidermization  is 
retarded,  the  edges  become  indurated  and  the  granulation  tissue  flabby. 
In  such  persons  the  diagnosis  is  not  difficult  if  there  is  a  distinct  history 
of  an  injury  with  loss  of  skin,  or  after  a  burn  or  freezing  of  the  parts. 
The  ulcers  present  no  characteristic  appearances,  and  in  the  absence 


AFFECTIONS    OF   THE    SKIN    AND    SUBCUTANEOUS    TISSUES. 


545 


of  a  history,  a  diagnosis  as  to  the  cause  is  impossible.  In  some  cases  the 
ulceration  may  spread  and  encircle  the  hmb.  In  these  a  condition  of 
elephantiasis  often  accompanies  the  ulcer,  forming  a  vicious  circle  in  thus 
increasing  the  venous  congestion  which  prevents  the  healing  of  the  ulcer. 

2.  Varicose  Ulcers. — These  are  usually  situated  on  the  front  of  the 
lower  third  of  the  leg,  but  may  be  located  over  the  malleoh.     They  are 
irregular  in  form,  the  edges  are  rarely  sharply  cut,  i.  e.,  steep,  and  the 
floor  may  present  a  condition  vary- 
ing from  a  dirty  sloughing  appear- 
ance to  a  healthy,  red,  granulating 
surface. 

The  skin  around  the  edges  is 
usually  of  a  bluish-red  color,  and 
indurated.  It  may  show  evidences 
of  extensive  brownish  pigmentation 
and  chronic  eczema. 

The  diagnosis  can  be  made 
from  the  presence  of  accompany- 
ing varicose  veins,  in  the  area  of 
distribution  of  either  the  internal 
or  external  saphenous  veins,  or  of 
both.  Various  complications  may 
call  for  recognition,  such  as  acute 
inflammation  of  the  skin  around 
the  ulcer,  thrombosis  of  the  vari- 
cose veins  (see  page  563)  leading 
to  it,  or  an  erysipelas  starting  from 
the  edge  of  the  ulcer.  Carcinoma- 
tous changes  may  also  occur,  and 
can  be  recognized  by  the  rapid 
spread  of  the  ulcerated  area,  the 
marked  induration  and  elevation 
of  its  edges,  and  the  enlargernent 
of  the  regional  lymph-nodes  (Fig. 
132). 

In  some  cases  varicose  ulcers,  like  the  more  chronic  variety  of  trauma- 
tic ulcer,  may  completely  encircle  the  limb,  and  be  associated  with  elej^han- 
tiasis  of  the  entire  leg  from  tlie  knee  to  tlic  foot. 

3.  Syphilitic  Ulcers. — If  the  characteristics  of  these  are  borne  in 
mind,  there  is  usually  no  difficulty  in  their  diagnosis.  Their  outline  is, 
as  a  rule,  more  regular  than  is  the  case  with  varicose  ulcers.     They  are 

35 


Fig.  364. — Varicose  Ulcer  of  Leg.     (See  te.xt.) 


546 


THE    EXTREMITIES. 


either  round  or  serpiginous  or  kidney- shaped.  Their  edges  are  usually  so 
sharp  and  steep  that  they  look  as  though  they  had  been  punched  out 
with  a  die.  The  floor  is  covered  with  sloughing  fetid  granulation  tissue 
and  the  ulceration  usually  extends  quite  deeply  into  the  tissues. 

The  absence  of  a  history  of  trauma  and  of  varicose  veins  will  often 
enable  a  differentiation  from,  these  two  varieties  of  ulcerations  to  be  made. 

There  are  many  cases,  however, 
in  which  the  syphilitic  ulcer  ap- 
peared after  an  injury  or  is  accom- 
panied by  varicose  veins.  In  such 
cases  the  diagnosis  can  only  be 
made  if  (a)  there  is  a  clear  history 
of  syphihs;  (b)  the  outhne  and 
edges  are  as  just  described,  and 
(c)  the  ulcer  shows  marked  im- 
provement after  the  use  of  the 
iodids.  The  latter  test  is,  unfor- 
tunately, not  an  absolutely  infalli- 
ble one,  since  many  varicose  and 
other  slowly  healing  ulcers  are 
greatly  improved  through  the 
stimulating  influence  of  this  drug. 
4.  Trophic  Ulcers. — These  are 
the  result  of  some  disease  of  the 
peripheral  or  central  nervous  sys- 
tem. They  usually  occur  on  the 
sole  of  the  foot  (especially  in  ta- 
betic patients),  over  the  head  of 
the  first  metatarsal  bone.  Rarely 
they  are  found  upon  the  hand. 
They  present  a  round,  punched- 
out  appearance,  and  involve  the 
deeper  structures  of  the  foot,  in- 
cluding the  bones.  In  every  such 
case  an  examination  of  the  central  nervous  system  should  be  made  for 
evidence  of  disease  of  the  spinal  cord,  such  as  tabes  or  syringomyelia. 
The  condition  has  also  been  called  mal  pcrforans  pedis.  It  may  be 
simulated  by  an  ulceration  due  to  necrosis  of  skin  over  an  infected  bursa 
in  the  same  location  developing  beneath  a  callus,  with  suppuration  and 
ulceration  of  the  overlying  skin. 

5.  Blastomycotic  Ulcers. — These  may  occur  either  on  the  upper  or 


Fig.  365. — Perforating  Ulcer  of  the  Foot  in  a 
Tabetic  Subject  (Matas). 


AFFECTIONS    OF   THE    SKIN    AND    SUBCUTANEOUS    TISSUES. 


547 


lower  extremities,   but  more   often  on  the   latter   (Fig.    366).     Their 
presence    must    be  suspected  if    {a)   all  of    the  forms   of    ulcer  just 


Fig.  366. — Blastomycotic  Ulcerations  on  Dorsal  Surface  of  Lower  Third  of  Leg. 

Note  the  peculiar  warty  or  papillomatous  elevations  characteristic  of  this  variety  of  ulcer,  and  the  raised  edges, 

showing  multiple  areas  of  softening  or  miliary  abscesses  in  which  the  organisms  are  most  frequently  found. 


o'. 


described   have   been    excluded,  and  (b)    from    the    appearance,  viz., 
a   peculiar   warty   or    papillomatous    surface,    especially   around    the 
edges;    (c)   from   the   history   of    contact    with   horse    manure,    etc., 
and  (d)  from  finding  the 
characteristic     yeast     or- 
ganisms   (Fig.     367)     in 
the    secretion    or    in   the 
miliary   abscesses   of    the 
edge. 

6.  Tuberculous  Ulcer's. 
— These  are  quite  rare  on 
the  skin  of  the  extremities 
except  when  associated 
with  a  similar  affection  of 
the  deeper  structures. 
They  can  be  rccognizcMl 
by  the  characteristic  thin 
bluish  edges,  by  the  under- 
mined condition  of  the 
latter,  by  the  caseous  de- 
generation of  many  of  the 

granulations  covering  its  surface,  and  the  presence  of  enlarged  regional 
lymph-nodes. 


'%'■ 


T  K^^ 


Fig.  367. — MiCROPHOTOGRAPH  Showing  Blastomycotic  Or- 
ganisms IN  Sputum  from  Patient  Shown  m  Fig.  366 
(X  1200.) 


548  THE    EXTREMITIES. 

In  some  cases  of  infection  with  \irus  from  cattle,  etc.,  the  process  may- 
begin  as  an  ulcer  on  the  fingers  and  spread  along  the  lymph-vessels  to 
the  groin  or  axilla,  causing  multiple  ulcerations  T^ith  undermined,  thin, 
bluish  edges  and  cheesy  surface  (Fig.  368). 

In  some  forms  of  cutaneous  tuberculosis  the  ulceration  is  not  marked, 
but  instead  of  it  one  finds  a  condition  similar  to  that  mentioned  in  the 
blastomycotic  ulcers,  viz.,  papillomatous  excrescences.  The  latter,  how- 
ever, are  higher  and  more  apt  to  be  undermined  in  tuberculosis.  This  is 
the  form  commonly  known  as  the  verrucous  or  warty  variety  of  cutaneous 
tuberculosis. 

7.  Decubitus  Ulcers. — These  may  be  recognized  from  their  appear- 
ance at  places  which  are  subjected  to  pressure,  such  as  the  heel,  the 


Fig.  368. — TcBERCui-Osis  of  the  Skix  op  the  Left  Upper  Extremity. 
I,  Indicates  primary  focus  or  atrium  of  infection  from  a  tuberculous  steer;    2,  both  of  the  figures  2  are 
placed  upon  several  of  the  many  secondary  tuberculous  foci  along  the  course  of  the  lymph-vessels;  3,  tuberculous 
axillary  glands. 

extensor  surfaces  of  the  toes,  the  malleoh,  amputation  stumps,  great 
trochanter,  and  tuberosity  of  the  ischium.  The  cause  should  always  be 
searched  for,  viz.,  a  tight  or  ill-fitting  shoe,  disease  of  the  spinal  cord  or 
peripheral  nerves,  or  cachexia,  due  to  various  constitutional  causes,  such 
as  diabetes,  arteriosclerosis,  anemia,  etc. 

Gangrene. — Gangrene  occurs  far  more  frequently  in  the  lower  than 
in  the  upper  extremities.  In  the  diagnosis  of  gangrene  one  must  con- 
sider not  only  the  chnical  phenomena,  but  also  the  etiology  of  the  process. 
The  mode  of  onset  of  gangrene  varies  somewhat,  according  to  the  cause. 
In  the  forms  knoAMi  as  senile  and  pre-senile  gangrene,  the  actual  necrosis 
is  preceded  by  more  or  less  severe  pain  for  a  considerable  period  before 
any  discoloration,  etc.,  of  the  hmb  takes  place.     In  the  gangrene  due  to 


Fig.  370.— Senile  Gangrene. 
Note  sharp  line  of  demarcalion. 


AFFECTIONS    OF   THE    SKIN    AND    SUBCUTANEOUS    TISSUES. 


549 


Raynaud's  disease  the  process  is  also  preceded  for  a  long  time  by  a  blu- 
ish tinge  of  the  fingers  or  toes,  which  may  or  may  not  be  follo\Yed  by 
actual  gangrene. 

Gangrene  may  involve  one  or  more  toes  or  fingers,  or  an  entire  limb. 
It  may  at  other  times  appear  simply  as  single  or  multiple  patches.  In 
the  majority  of  forms  of  gangrene  the  direct  cause  is  a  cutting-off  of  the 
blood- supply.  The  result  is  the  same,  whether  the  anemia  be  due  to  an 
obstruction  to  the  flow  of  arterial  blood  or  some  infective  or  other  process 
which  prevents  the  return  of  the  venous  blood  of  the  limb.  In  a  rela- 
tively small  proportion  of  cases  the  gangrene  is  due  to  infection  with  the 
organisms  described  on  pages  534  and  535,  viz.,  the  bacillus  of  malignant 
edema  or  bacillus  aerogenes  capsulatus  of  Welch. 

If  the  dead  tissue  remains  dry,  we  speak  of  a  dry  gangrene  or  mum- 


FiG.  369. — Bed-sores  in  a  Case  of  Fractdre  of  the  Spine  ("International  Text-Book  of  Surgery")- 


mificaiion'.  If  it  becomes  moist,  the  process  is  termed  moisl  gangrene 
or  sphacelus.  In  both  forms  putrefaction  may  occur,  so  that  there  is  a 
marked  fetid  odor  with  toxemia  from  absorption  of  septic  products. 
Qinically,  it  is  useless  to  retain  the  terms  dry  and  moist  gangrene,  since 
one  may  pass  into  the  other  and  the  same  cause  may  at  one  time  pro- 
duce one  form  and  at  another  time  the  otlier  variety,  tlic  difference  in 
this  mode  of  action  being  more  one  of  infection  with  putrefactive 
organisms. 

The  diagnosis  of  the  presence  of  gangrene  itself  usually  presents  no 
difficulties.  The  part  may  become,  either  gradually  or  suddenly,  cold 
and  bluish.  Pressure  with  the  finger  over  the  discolored  area  shows  a 
very  slow  return  of  color.  This  bluish  discoloration  is  graduallv  re- 
placed by  a  black  or  green  hue.     These  changes  in  color  may  be  limited 


550 


THE   EXTREMITIES. 


Fig.  372. — Soles  of  Feet  in  Raynaud's  Disease. 

The  bluish-black  discoloration   of  beginning   gangrene  is  more 

marked  upon  the  right  than  upon  the  left  foot. 


to  the  area  originally  involved,  or  the  process  gradually  spreads.     In 

every  form,  except  those 
due  to  infection  of  wounds 
with  gangrene-producing 
organisms  (malignant 
edema  and  bacillus  aero- 
genes  capsulatus),  a  line 
of  demarcation  forms, 
separating  the  dead  from 
the  living  tissues.  Accom- 
panying the  above  local 
changes  one  finds  in  some 
of  the  forms,  especially  in 
those  due  to  obstruction 
or  injury  of  the  artery  of 
the  Hmb,  an  absence  of 
pulsation  at  the  points 
where  it  is  normally  to 
be  felt. 

The  constitutional  disturbances  vary  greatly.     In  some  they  are  very 
marked,  while  in  others  they 
are  slight. 

They  are  usually  due  to 
septic  intoxication  or  to  septi- 
cemia, and  have  been  fully  de- 
scribed on  pages  537  and  538. 
After  a  diagnosis  of  the  ex- 
istence of  gangrene  has  been 
made,  the  next  question  is  to 
determine  its  cause.  By  a  pro- 
cess of  exclusion  one  must  rule 
out  one  after  the  other  of  the 
following  forms,  viz. :  (a)  Senile 
and  pre- senile;  (&)  diabetic;  (c) 
injury  to  arteries  and  veins;  (d) 
freezing;  (e)  embolic;  (/)  fol- 
lowing one  of  the  infectious 
diseases;  (g)  symmetrical  or 
Raynaud's  disease;  (/;)  so- 
called  idiopathic  multiple;  (/)  ergotism;  (y)  carbolic  acid. 

The  principal  diagnostic  points  of  these  different  forms  are  as  follows: 


^• 


r 


Fig.  373. — Side  View  of  Feet  of  Patient  Suffering 

FROM  Raynaud's  Disease. 

The  bluish-black  discoloration  is  far  more  advanced  upon 

the  right  than  upon  the  left  foot. 


en      ^j 


o    ^    o 
^  3     a 


H    o. 


AFFECTIONS    OF   THE    SKIN   AND    SUBCUTANEOUS    TISSUES. 


551 


(a)  Senile  Gangrene. — This  may  occur  after  a  slight  injury,  and  is 
often  preceded  by  severe  pains  in  the  hmb,  or  a  feehng  of  numbness.  In 
other  cases  there  are  no  premonitory  signs,  and  the  first  warning  is  the 
appearance  of  a  gangrenous  spot  on  one  toe  or  on  the  dorsum.  Senile 
gangrene  is  invariably  a  ciisease  of  the  lower  extremities,  and  seldom 
extends  higher  than  the  middle  of  the  leg.  The  absence  of  pulsation  in 
the  dorsalis  pedis,  posterior  tibial,  popliteal,  and  femoral  arteries  is  a 
prominent  symptom.     It  may  involve  one  or  both  limbs  (Fig.  370). 

Presenile  Gangrene. — This  occurs  in  middle-aged  or  even  young  per- 
sons. All  writers  agree 
that  the  cause  is  an 
arteriosclerosis  with 
occlusion  of  the  ves- 
sel, as  in  the  true  senile 
form.  The  predispos- 
ing causes  are  tobac- 
co, alcohol,  syphilis, 
trauma,  and  diabetes. 
The  gangrene  is  often 
preceded  by  a  group 
of  symptoms  termed 
intermittent  claudica- 
tion, first  described  by 
Charcot,  in  1859.  The 
patients  complain  of 
stiffness  and  pain  in 
the  calf  of  the  leg  on 
walking,  so  that  they 
limp.  The-  foot  and 
leg  show  extreme  pal- 
lor on  walking.       In 

some  cases  an  ulcer  may  appear  on  the  toes,  which  gradually  increases 
in  size,  and  is  very  painful.  There  is  no  pulsation  in  the  arteries  at  an 
early  stage. 

{h)  Diabetic  Gangrene. — There  are  two  distinct  forms,  the  inflam- 
matory and  non-inflammatory,  as  is  the  case  in  senile  gangrene.  In  the 
inflammatory  there  is  considerable  edema,  tenderness,  and  febrile  re- 
action, with  gradual  spreading  of  the  gangrene.  In  the  non-inflamma- 
tory form  the  process  is  slower  and  there  is  a  mummification.  Both 
varieties  of  diabetic  gangrene  are  due,  not  to  the  diabetes  itself,  but, 
in    the    majority   of    cases,  to     the   coexisting    arteriosclerosis.      The 


Fig.  374. — Enormous  Elephantiasis  of  Both  Lower  Extremities. 


552 


THE   EXTREMITIES. 


diagnosis,  therefore,  of  this  form  can  only  be  made  by  examining  the 
urine  for  the  presence  of  sugar. 

(c)  Gangrene  from  Injury  to  the  Arteries  or  Veins  of  a  Limb. — Atten- 
tion has  been  called  to  this  form  of  gangrene  on  page  430.  The  diagnosis 
of  this  form  can  be  made  if  the  changes  in  the  color  of  a  hmb,  accom- 
panied by  absence  of  pulsation 
in  its  palpable  arteries,  follow 
within  a  few  hours  to  several 
days  after  an  injury.  It  is 
especially  frequent  after  supra- 
condyloid  fractures  of  the 
femur,  or  separation  of  the 
lower  epiphysis,  and  also 
after  severe  crushing  injuries 
of  the  upper  or  lower  extremi- 
ties. 

(d)  Gangrene  from  Frost- 
bites.—  This  cause  can  be 
readily  recognized  from  the 
history,  although  the  possibil- 
ity of  this  variety  occurring  in 
a  person  suffering  from  ar- 
teriosclerosis or  diabetes  must 
not  be  forgotten. 

(e)  Embolic  Gangrene. — 
This  form  is  due  to  the  block- 
ing of  the  lumen  of  one  of  the 
larger  arteries,  such  as  the 
brachial,  femoral,  or  popli- 
teal. It  occurs  in  elderly  per- 
sons as  the  result  of  an  endo- 
carditis. The  gangrene  of  the 
limb  occurs  far  more  rapidly 
than  in  the  senile  form,  and 
can  only  be  distinguished  from 

it  by   the   sudden   onset   and  the    presence  of   evidences  of  valvular 
disease. 

(/)  Gangrene  in  the  Course  of  the  Infectious  Diseases. — It  is  most 
often  due  to  an  infective  process  in  the  artery  with  or  without  accom- 
panying venous  thrombosis.  It  occurs  in  typhoid,  typhus,  puerperal 
infection,  measles,  scarlatina,  pneumonia,  malaria,  and  acute  articular 


Fig.  375. — General  Keloidal  Disease  in  a  Negro 
WITH  MoLLuscuM  FiBROsuM  (Matas). 


AFFECTIONS    OF   THE    SKIN    AND    SUBCUTANEOUS    TISSUES. 


553 


rheumatism.  Of  all  of  these,  those  complicating  typhoid  constitute  the 
majority  (forty-four  of  sixty-eight  cases,  collected  by  Barraud^).  The 
clinical  signs  are  the  same  as  those  of  other  forms  of  gangrene.  The 
diagnosis  can  be  made  from  the  gangrene,  absence  of  pulsation,  and  the 
history  of  the  preced- 
ing disease. 

(g)  Gangrene  due 
to  Raynaud's  Disease. 
— This  form  can  be 
recognized  from  the 
history  of  a  bluish  dis- 
coloration of  the  fin- 
gers or  toes,  or  both, 
accompanied  by  severe 
pain  existing,  in  some 
cases,  for  years  before 
the  onset  of  the  gan- 
grene. The  latter  is 
characterized  by  its 
symmetrical  distribu- 
tion (Fig.  371),  and 
the  bluish  or  asphyc- 
tic hue  is  often  very 
marked  in  the  adja- 
cent skin  or  toes.  The 
disease  may  not  be 
confined  to  the  ex- 
tremities, but  involve 
symmetrical  areas  on 
the  trunk. 

Of  the  other  forms 
of  gangrene,  the  diag- 
nosis of  those  due  to 
carbolic  acid  or  ergot- 
ism can  only  be  made 

from  the  history  of  the  use  of  these  drugs.  That  due  to  ergotism  is  very 
rare,  and  the  form  resulting  from  the  appHcation  of  even  weak  solutions 
of  carbolic  acid  is  infrequent,  since  the  latter  is  seldom  used  as  a  wet 
dressing  at  the  present  time. 

The  diagnosis  of  idiopathic  multiple  gangrene  should  only  be  made 

*  "Deutsche  Zeitschrift  f.  Chirurgie,"  vol.  Ixxiv. 


Fig.  376. — Anterior  View  of 
Same  Patient  Shown  in 
Fig.  377- 

Note  the  many  pedunculated 
fibromata. 


Fig.  377. — Posterior  View  of 
Marked  Case  of  Multiple 
Fibroma  Molluscum. 


554 


THE    EXTREMITIES. 


if  all  of  the  above-named  causes  have  been  carefully  excluded.  Many 
case  of  gangrene  without  any  obvious  cause  have  been  reported  in  young 
or  middle-aged  persons. 


Surgical  Diseases  of  the  Skin- 
Elephantiasis. — This  chronic  diffuse  hypertrophy  of  the  skin  has 
already  been  referred  to  as  a  complication  of  extensive  ulcers  of  the  leg, 

especially  those  of  the  trau- 
matic variety.  It  causes 
enormous  enlargement  of 
the  foot  and  leg,  or  of  the 
entire  limb.  At  times  both 
lower  extremities  are  in- 
volved (Fig.  374). 

The  limb  is  enormously 
swollen,  is  very  firm,  of  a 
grayish  color,  and  covered, 
especially  around  the  ankle 
and  upon  the  foot,  by  in- 
numerable pigmented  papil- 
lary excrescences.  In  places 
deep  furrows  are  seen  inter- 
rupting the  swelhng.  It  is 
a  disease  due  to  pathologic 
changes  in  the  lymph- vessels 
of  the  skin,  consisting  of 
great  thickening  of  their 
walls  and  cystic  dilatation 
of  the  vessels  themselves. 

It  is  of  interest,  from  a 
diagnostic  point  of  view,  to 
search  for  the  cause.  In 
some  cases  seen  in  tropical 
chmates  it  is  due  to  the 
filaria  sanguinis  hominis, 
which  obstructs  the  lymph-vessels.  In  our  own  northern  climate  the 
disease  may  be  due  (a)  to  interference  with  return  circulation  through 
ulcers  which  almost  encircle  the  limb;  (b)  to  chronic  inflammatory  pro- 
cesses, such  as  eczema. 

In  persons  suffering  from  this  condition  there  arc  attacks  of  acute 


Fig.  378. — Posterior  View  OF  A  Case  of  Diffuse  Multiple 
Cutaneous  Fibromata.     (See  text.) 


SURGICAL   DISEASES    OF   THE    SKIN. 


555 


inflammation  of  the  area  from  time  to  time,  similar  to  those  ah-eady 
referred  to  in  lymphangiomata    (see  page  134).     The  limb   becomes 
reddened,    very   tender,   and    feels   hot.     The    swelling    is    increased, 
and  these  symptoms  are  accompanied 
by  a  rise  in  temperature.     Such  attacks 
last  from  a  few  days  to  weeks,  and  then 
the  symptoms  disappear. 

Keloid. — This  is  a  peculiar  tumor- 
like formation  of  the  skin,  which  either 
develops  in  the  scar  of  some  wound  or 
arises  spontaneously.  In  the  former 
case  it  is  most  apt  to  occur  in  those 
having  a  history  of  tuberculosis,  as  well 
as  in  the  negro  race.  They  may  be 
Hmited  to  a  scar,  or  may  grow  quite 
diffusely.  The  spontaneous  form  is 
rare,  and  does  not  appear  on  the  ex- 
tremities. Its  favorite  locations  are 
over  the  sternum  and  front  of  the  shoul- 
ders (Fig.  374).  In  both  the  traumatic 
and  spontaneous  varieties  the  appear- 
ance and  slow  growth  are  the  same. 

It  feels  firmer  than  the  surrounding 
skin,  above  whose  level  it  rises  slightly. 
It  is  of  a  dull  reddish  color,  and  ex- 
tends over  the  entire  length  of  the  scar, 
even  involving  the  cicatrices  following 
the  suture  openings  in  the  skin. 

Tumors  of  the  Skin  and  Subcu- 
taneous Tissue. — -The  diagnosis  of  tumors  of  the  skin  does  not  differ 
from  that  of  similar  conditions  elsewhere. 

The  various  forms  of  tumors  which  occur  in  the  skin  of  the  extremities 


Fig.  379. — Sebaceous.  Cyst  in  Popliteal 
Space,  Resembling  Semi-membrano- 
sus  Bursa. 


are: 

Benign. 

1.  Hemangioma  (capillary  and  venous). 

2.  Lymphangioma. 

3.  Fibroma  (soft  and  hard). 

4.  Lipoma. 

5.  Benign  epithelial  wart  (papilloma). 

6.  Moles  (congenital  and  acquired). 

7.  Sebaceous  and  dermoid  cysts. 

8.  Adenoma  of  sebaceous  or  sweat  glands. 


Malignant. 
Sarcoma: 

(0)  Spindle-  and  round-celled. 

(b)  Hemangiosarcoma. 

(c)  Lymphangiosarcoma. 

(d)  Mycosis  fungoides. 
Carcinoma: 

(u)  Malignant  warts. 

(b)  Rodent  ulcers. 

(c)  Epithelioma  proper. 

(d)  .Adenocarcinoma    arising    in  the 

sweat  and  sebaceous  glands. 


556 


THE    EXTREMITIES. 


I 


In  attempting  to  make  a  diagnosis,  the  following  points  must  be 
considered :  (a)  The  question  of  whether  the  tumor  has  grown  slowly 
or  rapidly;  (b)  the  period  when  first  noticed,  whether  at  birth,  before 
middle  age,  or  after  the  latter  period;  (c)  the  chnical  appearances;  (d) 
evidences  of  metastases,  and,  lastly,  (e)  the  results  of  the  microscopic 
examination. 

Of  the  above  tumors,  the  majority  of  those  in  the  benign  group  re- 
quire no  special  description  here. 

Hemangioma  and  lymphangioma  are  most  often  found  in  children, 
and  may  involve  an  entire  hmb,  especially  the  upper.  The  soft  iibroma 
is  usually  a  part  of  a  generahzed  condition  (see  Fig.  376).     The  hard 

variety  must  be  distin- 
guished from  keloids. 
It  is  smooth  and  hard, 
and  may  become  pedun- 
culated, and  appears  in- 
dependently of  scars. 

A  denom  aof  the  sweat 
and  sebaceous  glands  is 
found  chiefly  in  the  ax- 
illa as  a  hard,  round  no- 
dule, lying  just  beneath 
the  skin. 

Sebaceous  and  der- 
moid cysts  are  quite  rare 
in  the  extremities,  but 
the  former  may  be  en- 
countered in  unexpect- 
ed locations  (see  Fig. 
379).  They  lie  just  be- 
neath the  skin,  which  is  freely  movable  over  them  unless  they  have 
become  adherent  to  it. 

In  addition  to  the  ordinary  papillary  wart  found  especially  often  on 
the  hands  and  feet,  a  fibropapillary  hypertrophy  may  occur,  which  at 
first  may  resemble  an  epithelioma,  but  is  softer  and  slower  in  growth. 
The  appearance  of  moles  does  not  differ  from  that  of  the  same  growths 
elsewhere.  They  may  show  a  tendency  to  become  malignant  by  ulcera- 
tion, especially  in  later  life,  and  more  often  in  those  having  a  smooth  than 
a  warty  surface. 

Malignant  Tumors. — Of  these,  the  spindle-  and  ronnd-celled  sarcomata 
rarely  arise  from  the  connective  tissue  of  old  scars.     More  frequently 


Fig.  380. — Cavernous  Hemangioma  of  Outer  Aspect  of  Right 
Gluteal  Region. 


DISEASES    OF   THE    ARTERIES. 


557 


they  have  their  origin  in  the  fasciae  between  the  skin  and  muscles.  They 
grow  very  rapidly,  as  a  rule,  especially  the  round-celled  variety,  and 
lift  up  the  overlying  skin. 

The  hemangiosarcomata  belong  to  the  peritheliomata,  and  represent 
a  malignant  change  in  a  previously  existing  hemangioma.  Often  the 
case  is  seen  when  a  history  of  such  a  preceding  angioma  cannot  be 
obtained,  and  the  diagnosis  of  its  nature  is  impossible  without  micro- 
scopic examination. 

The  lymphangiosarcomata  represent  a  malignant  change  either  in  a 
preexisting  lymphangioma  or  in 
a  congenital  mole. 

The  malignant  tumors  of  the 
epithelial  type  are  not  difficult  to 
diagnose.  They  all  show  an  in- 
durated base  and  adhesions  to 
the  underlying  structures.  The 
ordinary  type  of  epithelioma 
most  frequently  develops  in  old 
ulcers,  resulting  from  varicose 
veins,  or  in  those  due  to  former 
trauma  or  to  burns.  Such  a 
malignant  change  can  be  recog- 
nized by  the  steady  growth  of 
the  ulcer,  and  the  marked  in- 
duration of  its  base  and  edges 
(Fig.  383 ) .  An  epithelioma  may 
rarely  occur  as  a  primary  tumor 
in  the  skin  without  previous  ul- 
ceration (Figs.  132  and  133). 

Rodent  ulcers  rarely  develop 
in  the  skin  of  the  extremities. 

They  grow  very  slowly,  and  do  not  produce  metastases  in  the  regional 
lymph-nodes,  as  do  the  other  iorms  of  superficial  carcinomata.  Adcno- 
carcinomata  0}  the  sweat  or  sebaceous  glands  arc  both  very  rare  tumors 
in  the  extremities,  and  would  be  most  Hkely  to  occur  in  the  axiha  or  groin. 


Fig.  381. — Sarcoma  of  Dorsum  of  Foot. 
The  black  area' at  its  upper  level  was  an  area  of  ulcer- 
ation covered  with  granulation  tissue. 


DISEASES  OF  THE  ARTERIES. 

The  most  frcc^ucnt  surgical  diseases  of  the  arteries  are  inllamma- 
tions  of  the  vessel  wall  (arteritis)  and  aneurysms. 

An  arteritis  is  always  secondary  to  some  infective  focus  clsewliere. 


'558 


THE   EXTREMITIES. 


If  a  septic  embolus  lodges  in  an  artery  it  causes  a  suppurative  inflamma- 
tion of  the  wall  of  the  vessel  and  the  formation  of  an  abscess  around 
the  arter}\  In  the  case  shown  in  Fig.  362  such  an  infection  followed 
suddenly,  after  a  gangrene  of  the  lung,  the  embolus  lodging  in  the  bra- 
chial artery.  A  diagnosis  can  only  be  made  from  the  existence  of  a  septic 
focus  elsewhere  followed  by  the  sudden  appearance  of  evidences  of  in- 
fection around  an  arterv  of  the  extremities. 


Fig.  382. — Epithelioma  of  Inner  Aspect  of  Right  Thigh  in  a  Woman  of  Fifty-five. 


Aneurysms. 
Cirsoid  Aneurysms. — In  connection  with  diseases  of  the  scalp  it 
was  stated  that  the  majority  of  cirsoid  aneurs^sms  occur  in  the  frontal 
and  temporal  arteries.  They  have  also  been  observed  in  the  hands  and 
fingers,  being  more  common  in  women  than  in  men  in  the  proportion  of 
ten  female  to  six  male  in  the  sixteen  cases  collected  by  Wagner.^  The 
diagnosis  presents  no  difficulty.  The  tumor  is  soft,  compressible,  and 
pulsates,  and  one  can  feel  distinctly  the  outhne  of  the  vessels  composing  it. 
On  auscultation  one  hears  a  soft-blowing  intermittent  murmur.  Its 
differentiation  from  an  angioma  of  the  venous  type  and  from  an  arterio- 
venous aneurysm  has  been  discussed  on  page  433. 

'  Beitrage  zur  klinischen  Chirurgie,  vol.  xi,  p.  49. 


DISEASES    OF   THE    ARTERIES. 


559 


Non-traumatic  Aneurysms  of  the  Larger  Vessels  of  the  Ex- 
tremities.— The  fact  that  an  aneurysm  may  follow  a  blow  upon  an 
artety  or  a  penetrating  wound  with  rupture  of  its  coats  has  already 
been  referred  to.  True  aneurysms  not  infrequently  occur  in  the  larger 
arteries  of  the  upper  and  lower  extremities,  whose  origin  is  due  to  athero- 
matous degeneration  of  the  vessel  wall.  In  such  patients  the  history 
of  a  preceding  syphilis,  of 
abuse  of  alcohol,  of  gout,  or 
diabetes  is  usually  to  be  ob- 
tained. 

There  is  no  longer  any 
question  that  trauma  plays  a 
certain  role  in  these  cases,  since 
they  most  often  occur  in  men 
who  are  obliged  to  do  hard 
work.  Under  these  conditions 
degenerated  arteries  are  more 
likely  to  rupture  and  form  an 
aneurysm. 

Of  a  total  of  five  hundred 
and  ninety-one  aneur}'sms  col- 
lected by  Crisp,  three  hundred 
and  eight  were  found  in  the 
arteries  of  the  extremities. 
These  involved  the  popliteal 
artery  in  one  hundred  and 
thirty- seven  cases  and  the 
femoral  in  sixty-six,  so  that  it 
may  be'  said  that  aneur}''sms 
affect  these  two  vessels  more 
frequently  than  any  of  the 
others  of  the  extremities.  The 
axillary    (sixteen    cases)    and. 

brachial  (one  case)  and  the  smaller  vessels  of  the  forearm  and  leg  are 
rarely  affected.  The  diagnosis  of  a  non-traumatic  aneurysm  does  not 
differ  from  that  of  the  non-traumatic  already  given  except  in  these  two 
points:  (a)  There  is  usually  no  history  of  a  single  injury,  although  there 
may  be  that  of  repeated  ones,  and  (b)  the  swelling  itself  is  more  apt  to  be 
circumscribed.  The  tumor  is  usually  to  be  outlined  distinctly ;  it  is  ovoid, 
round,  or  spindle-shaped.  Its  characteristic  signs  are:  (a)  A  pulsation 
which  is  expansile  in  character  and  can  be  best  felt  by  grasping   the 


Fig.  383. — Popliteal  Aneurysm. 
The  arrow  points  to  the  prominence  over  the  middle 
of  the  popliteal  space  due  to  the  aneurysmal  sac.     Note 
the  dilated  and  varicose  condition  of  the  superficial  veins 
on  the  outer  aspect  of  the  same  limb. 


56o 


THE   EXTREMITIES. 


tumor  between  the  thumb  and  index-iinger  (see  Fig.  386).  This  pul- 
sation is  synchronous  with  that  of  the  pulse  at  the  wrist  or  some  other 
superficial  artery,  (b)  A  distinct  blowing  murmur  is  to  be  heard  with 
the  stethoscope  which  is  also  synchronous  with  the  pulse.  The  tumor 
itself  can  be  felt  in  the  majority  of  cases  to  be  directly  connected  with 
the  arter}^  involved  and  a  peculiar  thrill  is  felt  with  every  pulsation. 
Pressure  upon  the  vessel  on  the  proximal  side  of  the  aneurysm  causes 
both  the  pulsation  and  murmur  to  be  diminished  or  even  disappear. 


Fig.  384. — Posterior  View  of  a  Case  of 
Non-traumatic  Popliteal  Aneurysm, 
Showing  Location  (Black  Circle)  of 
Prominence  at  Back  of  Knee. 


Fig.  385. — Lateral  View  of  Non-traumatic  Popli- 
teal Aneurysm. 
The  black  arrow  points  to  the  prominence  at  the  back 
of  the  left  knee.     Same  case  shown  in  Fig.  384. 


An  aneurysm  must  be  differentiated  from  pulsating  neoplasms,  es- 
pecially osteosarcomata.  The  latter  grow  more  rapidly  and  feel  harder 
than  an  aneurysm,  and  the  pulsation  is  more  diffuse,  and  not  expansile, 
but  has  a  more  lifting  character. 

Aneurysms  of  the  femoral  arter}^  must  be  differentiated  from  a 
femoral  hernia  or  a  psoas  abscess  by  the  absence,  in  both  of  the  latter, 
of  expansile  pulsation  and  a  murmur  and  the  fact  that  the  tumor  can 
usually  be  reduced.  In  the  case  of  a  psoas  abscess  the  swelling  shows 
more  distinct  fluctuation,  and  there  are  evidences  of  spinal  disease. 


DISEASES    OF    THE   VEINS. 


561 


If  an  aneurysm  begins  to  show  e\idences  of  infection  with  involve- 
ment of  the  surrounding  tissues  the  diagnosis  becomes  very  difficult. 
There  is  high  fever  present,  the  swelling  does  not  pulsate,  and  there  are 
all  the  local  evidences  of  a  phlegmon.  In  a  case  occurring  in  the  service 
of  one  of  my  colleagues  an  aneurysm  of  the  femoral  artery  ruptured 
spontaneously  and  the  patient  succumbed  to  the  hemorrhage,  some 
hours  after  incision  was  made  in  the  infected  area,  upon  a  diagnosis 
of  a  phlegmon.  In  case  of 
doubt  it  is  always  best  to 
observe  the  case  a  few  days 
before  makino;  a  diagnosis. 


DISEASES  OF  THE  VEINS. 

Phlebitis  and  Throm- 
bosis.— Inflammation  of  a 
vein  involves  all  of  the  coats 
of  the  vessels  and  often 
the  tissues  immediately  sur- 
rounding it.  The  disease 
occurs  in  an  acute  and  sub- 
acute form.  The  acute  form 
can  be  recognized  by  the 
presence  of  marked  redness 
of  the  skin  over  the  vein, 
great  tenderness  on  press- 
ure, and  swelHng  of  the  soft 
tissues  around  the  vein.  The 
outHne-of  the  vein  itself  can 

be  felt  as  an  extremely  tender  cord,  especially  if  a  superficial  vein  like  the 
internal  saphenous  is  involved.  Accompanying  these  local  phenomena 
there  is  high  fever,  prostration,  and  rapid  pulse.  If  septic  emboli  become 
detached  and  float  into  the  circulation,  a  pyemia  results.  Such  virulent 
cases  fortunately  are  rare.  In  the  majority  of  cases  of  phlebitis  the 
disease  runs  a  subacute  or  chronic  course.  The  chief  diagnostic  points 
are  (a)  the  presence  of  pain  and  tenderness  along  the  course  of  the  vein; 
(6)  edema  of  the  limb  below  the  point  of  thrombosis,  if  the  thrombosis 
involves  the  deeper  veins;  (c)  if  the  vein  is  a  superficial  one  it  can  be  felt 
as  a  tender  firm  cord.  If  the  condition  occurs  as  a  compHcation  of 
varicose  veins,  the  latter  become  very  tender  and  hard,  the  thrombi  oc- 
cupying ever\'  portion  of  the  varicosities.  The  skin  over  them  is  red 
36 


Fig.  386. — Anterior  View  of  External  Iliac  (i)  and 
Femoral  (2)  Aneurysms,  showing  Method  of  Pal- 
pation OF  AN  Aneurysmal  Sac  for  Expansile  Pul- 
sation. 


562 


THE    EXTREMITIES. 


and  exceedingly  sensitive  to  the  touch.  Such  a  subacute  phlebitis  is 
apt  to  follow  (a)  an  infection  of  the  soft  parts  of  an  extremity;  (b)  any 
one  of  the  acute  general  infections,  such  as  typhoid,  pneumonia,  rheu- 
matism, or  (c)  occur  in  alchohsm,  or  (d)  as  a  phlegmasia  alba  dolens  in 
puerperal  infection. 

Even  though  the  inflammatory  symptoms  disappear,  the  edema  of 

the  extremity  may  persist  for  months  to 
years. 

A  not  infrequent  complication  of  a 
thrombophlebitis  of  the  deeper  veins  of 
the  lower  extremity  is  the  appearance  of 
ulcers  (page  545)  which  are  very  obstinate 
to  treatment. 

Thrombophlebitis  may  occur  after 
operations  and  shoAv  no  clinical  signs  ex- 
cept a  slight  local  tenderness.  Even  the 
latter  may  be  absent,  and  the  first  symp- 
tom may  be  the  onset  of  symptoms  of  pul- 
monary embolism  described  as  a  post- 
operative complication  on  page  702. 

Varicose  Veins. — This  condition  is 
almost  exclusively  confined  to  the  lower 
extremities,  although  it  also  occurs  in  the 
veins  of  the  spermatic  plexus  as  a  varico- 
cele. It  affects  chiefly  the  internal,  less 
often  the  external,  saphenous  vein. 

In  the  majority  of  cases,  varicose  veins 
cause  no  symptoms  until  complications 
appear.  In  a  small  percentage  of  cases 
attention  is  first  called  to  their  presence 
by  the  occurrence  of  pain  referred  along 
the  line  of  the  vein.  If  uncomplicated, 
the  varicose  veins  can  be  felt  as  soft  tor- 
tuous cords.  The  skin  over  them  is 
stretched  so  that  the  bluish  color  of  the 
vessel  shows  through.  At  times,  the  most  prominent  mass  is  found  over 
the  internal  condyle  of  the  femur.  The  individual  dilatations  may  be 
so  large  as  to  simulate  cystic  tumors  or  other  conditions.  The  tumor- 
like form  is  especially  seen  near  the  saphenous  opening  in  Scarpa's 
triangle.  The  soft  dilatation  of  a  varicosity  may  resemble  a  femoral 
hernia  (see  page  415)  or  a  psoas  abscess.     One  of    the  best  methods 


Fig.   387. — Varicose   Veins    ("Inter- 
national Text-Book  of  Surgery")- 


DISEASES    OF   THE    LYMPH- VESSELS. 


56: 


of  determining  the  extent  of  the  varicosities  is  to  compress  the 
main  trunk  of  the  internal  saphenous  vein  at  the  middle  of  the  thigh. 
The  cliiej  complications  of  varicose  veins  are  (i)  ulceration;  (2)  sub- 
acute phlebitis,  with  the  formation  of  thrombi  and  phlebohths;  (3)  hem- 
orrhage from  rupture  of  a  varicosity ;  (4)  chronic  eczema  and  pigmentation 
of  the  limbj^with  the  development  of  an  elephantiasis.     Varicosities  of 


Fig.  388. — Method  of  Palpating  the  Axillary  Lymph-nodes. 
The  same  method  may  be  used  in  both  sexes.     The  patient's  arm  is  laid  upon  the  examining  arm  of  the 
surgeon,  after  the  fingers  of  the  latter  have  been  passed  along  the  thoracic  wall  to  the  apex  of  the  axilla.     In 
this  manner  the  axillary  fascia  is  relaxed  and  the  examining  lingers  can  be  inserted  much  higher  than  by  any 

other  method. 

the  deeper  veins  can  be  recognized  (a)  by  the  presence  of  edema  around 
the  ankle  without  other  ascertainable  cause;  (b)  the  dilatation  of  the  finer 
veins  of  the  dorsum  of  the  foot. 


DISEASES  OF  THE  LYMPH-VESSELS. 
Acute  lymphangitis  has  been  referred  to  in  connection  with  infection, 
of  the  extremities,     lis  presence  can  be  recognized  by  the  occurrence  of  a 


564  THE   EXTREMITIES. 

red  streak  in  the  skin,  leading  from  the  seat  of  infection  to  the  axilla  or 
groin,  as  the  case  may  be.  The  inflamed  lymph-vessel  can  also  be 
palpated  as  a  firm,  tender  cord,  lying  just  beneath  the  skin.  Abscesses 
may  form  in  the  course  of  the  vessel  opposite  its  valves. 

Chronic  lymphangitis  occurs  in  the  extremities  chiefly  in  a  tuber- 
culous form  (Fig.  368).     The  atrium  of  infection  may  be  on  the  hand  or 


Fig.  389. — Method  of  Palpating  the  Cubital  Lymph-nodes. 
The  examiner  should  stand  in  front  of  and  to  the  right  or  left  of  the  patient,  according  to  the  side  to  be 
examined,  and  grasp  the  elbow  in  such  a  manner  that  the  tips  of  the  fingers  rest  upon  the  humerus  just 
above  the  internal  condyle.     The  nodes  are  to  be  felt  .between  the  inner  edge  of  the  biceps  and  the  space 
just  above  the  internal  condyle  of  the  humerus. 

foot.  The  lymph- vessel  itself  feels  hard  and  nodular,  and  may  break 
down  opposite  the  valves  into  multiple  foci  of  suppuration  with  the  for- 
mation of  typical  tuberculous  ulcers.  Such  an  infection  may  come  from 
bovine  tuberculosis,  as  in  the  case  shown  in  Fig.  368. 

Lymph  Cysts. — These  are  quite  rare,  arising  as  the  result  of  the  ob- 
struction of  a  lymph- vessel  through  trauma  and  occurring  most  frequently 
in  the  thigh  as  large  cystic  tumors  whose  origin  is  usuahy  not  recognized 


DISEASES    OF   THE   LYMPH-NODES, 


56  = 


until  operated  upon.  They  present  themselves  as  cystic  tumors  in  the 
groin  or  thigh  which  must  be  differentiated  from  a  hydrocele  of  the  canal 
of  Nuck,  from  lipoma,  from  blood-cysts,  and  from  tuberculous  abscesses. 


DISEASES  OF  THE  LYMPH-NODES. 

Tliis  subject  has  been  fully  discussed  in  the  chapter  on  the  neck. 
The  lymph-nodes  of  the  extremities,  which  are  most  frequently  involved, 
are  the  cubital,  axillary,  and  inguinal.  The  diagnosis  of  an  acute  in- 
fammatiGn  presents  no  difficulties.     The  nodes  can  be  felt  as  round 


Fig.  390. — Method  of  Palpating  Inguinal  Lvmph-nodkk. 
The  examining  hand  is  placed  flat  upon  the  anterior  aspect  of  the  thigh,  the  finger-tips  resting  on  Pou part's  liga- 
ment; or  rather  the  skin  overlying  it,  and  the  nodes  thus  palpated  by  a  rolling  motion  of  the  hngcr-tips. 

tender  tumors,  which  later  become  matted  together  and  show  e\'idenccs 
of  suppuration,  such  as  superficial  redness  and  lluctuation.  It  is  of  great 
importance  to  remember  that  the  primary  focus  of  infection  may  have 
healed  and  perhaps  have  been  forgotten,  when  the  ])atient  presents  him- 
self with  all  of  the  e\'idences  of  acute  inllammalion  of  tlie  cubital,  axil- 
lary, and  inguinal  nodes.  This  clinical  fact  is  especially  to  be  found  in 
children.  Suppuration  of  the  inguinal  nodes  most  frequently  follows 
gonorrhea  or  soft  chancroids. 


566  THE    EXTREMITIES. 

Chronic  Inflammation  of  the  Lymph-nodes. — As  was  found  to 
be  the  case  in  the  neck,  the  percentage  of  tuberculous  involvement  is  far 
greater  than  that  from  any  other  cause.  Tuberculosis  of  the  inguinal 
nodes  is  quite  rare,  while  that  of  the  axillarv'  nodes  is  a  frequent  com- 
plication of  the  same  affection  of  the  neck. 

When  enlarged  nodes  are  found  in  the  axilla,  the  groin,  or  the  cubital 
region,  one  must  exclude  one  by  one  the  following  forms  of  enlargement  of 
the  lymph-nodes,  by  the  diagnostic  landmarks  mentioned  on  pages  169 
to  172:  (a)  Tuberculosis;  (b)  syphilis;  (c)  simple  chronic  hyperplasia  as 
the  result  of  long-continued  irritation;  (li)  lymphosarcoma ;  (e)  lymphatic 
leukemia;  (/)  Hodgkin's  disease;  (g)  secondarv'  carcinomatous  en- 
largement. In  connection  with  the  last  named  it  is  important  to  call  at- 
tention to  the  fact  that  quite  malignant  tumors  of  the  breast  cause  early 
enlargement  of  the  axillary  nodes.  Carcinoma  of  the  prostate  or  of  the 
lowermost  portions  of  the  rectum  and  vagina  may  cause  enlargement 
of  the  inguinal  nodes  at  an  early  date.  If  one  find  enlarged  and  hard 
inguinal  nodes  in  an  elderly  person  a  search  for  such  a  primary  cancer 
should  alwavs  be  made. 


DISEASES  OF  THE  BURS^. 

In  order  to  be  able  to  make  a  diagnosis  one  must  recall  the  location  of 
the  more  important  bursae.  These  are  (a)  the  subdeltoid,  lying  beneath 
the  deltoid  muscle;  (b)  the  olecranon;  (c)  the  metacarpo-phalangeal; 
(d)  the  ischial,  over  the  tuberosity  of  the  ischium;  (e)  the  trochanteric, 
over  the  greater  trochanter;  (/)  the  prepatellar;  (g)  one  between  the 
tendo  Achillis  and  the  os  calcis;  (h)  the  ileopsoas  bursa;  (i)  one  over 
the  head  of  the  metatarsal  bone  of  the  great  toe;  (f)  the  semimembra- 
nous bursa  (Fig.  265). 

Acute  bursitis  as  the  result  of  trauma  has  already  been  referred  to. 
A  similar  condition  may  follow  infection  of  the  neighboring  or  even  dis- 
tant parts.  Such  an  acute  inflammation  has  been  repeatedly  observed 
in  gonorrhea,  involving  most  frequently  the  achillean  and  prepatellar 
bursae.  Acute  bursitis,  whatever  the  cause  may  be,  can  be  recognized 
when  a  tender  swelling  appears  at  a  point  corresponding  to  one  of  the 
above  normal  bursal  locations.  The  skin  over  the  inflamed  bursa  may 
be  red  and  infiltrated.  The  direct  relation  of  the  subdeltoid  and  ileo- 
psoas bursae  to  the  shoulder-  and  hip- joints  respectively  is  of  great  sur- 
gical importance  in  acute  inflammations  of  these  bursae,  owing  to  the 
frequency  of  secondary  joint  involvement. 

Chronic  Bursitis. — In  these  there  is  a  painless  tumor,  often  as  large 


DISEASES    OF   THE    TENDONS    AND   TENDON-SHEATHS.  567 

as  a  hen's  egg,  showing  distinct  fluctuation  corresponding  to  the  various 
normal  positions  of  the  bursas.  The  majority  of  these  tumors  are  the  result 
of  chronic  irritation,  with  resultant  catarrhal  inflammation  of  the  serous 
lining  of  the  bursa  and  the  production  of  a  variable  quantity  of  fluid. 
The  latter  often  contains  many  small  rice  bodies.  The  diagnosis  pre- 
sents no  difficulty  unless  suppuration  has  occurred  and  a  sinus  formed. 
The  condition  under  these  circumstances  greatly  resembles  that  of  a 
sinus  leading  to  an  old  focus  of  osteomyelitis.  A  chronic  enlargement  of 
the  olecranon  bursa  has  been  given  the  name  "miner's  elbow,"  while 
that  of  the  prepatellar  bursa  is  called  "housemaid's  knee,"  although  both 
often  occur  independently  of  these  occupations. 

Tuberculous  and  syphilitic  bursitis  occur  less  frequently  than  the  or- 
dinary catarrhal  variety.  A  diagnosis  of  a  tuberculous  bursitis  can  only 
be  made  before  operation,  if  a  swelling  which  shows  distinct  crepitation 
(from  the  presence  of  many  rice  bodies)  appears  over  one  of  the  usual 
bursal  locations.  Syphilis  causes  a  gummatous  infiltration  of  the  wall, 
giving  rise  to  a  thick  indurated  mass  at  the  location  of  a  bursa. 


DISEASES    OF    THE    TENDONS    AND    TENDON-SHEATHS. 
Inflammatory  Affections. 

These  almost  invariably  involve  both  the  tendon  itself  and  the  ten- 
don-sheath. The  condition  may  be  either  primary  or  secondary.  It 
may  also  be  acute  or  chronic. 

Acute  Primary  Tenovaginitis  or  Tenosynovitis. — (a)  Tenova- 
ginitis  Crepitans. — This  occurs  only  in  the  extensor  sheaths  of  the 
thumb  after  excessive  use  or  exposure  to  cold.  It  may  be  recognized  by 
the  occurrence  of  sharp  pain  upon  extension  of  the  thumb,  accompanied 
by  distinct  crepitus.  The  latter  is  best  felt  when  the  fingers  are  placed 
along  the  course  of  the  tendon  as  far  as  the  middle  third  of  the  forearm, 
while  the  thumb  is  alternately  extended  and  flexed.  After  a  few  days  the 
pain  and  crepitus  disappear,  and  the  patient  may  have  an  oblong  swell- 
ing extending  from  the  back  of  the  thumb,  obliquely  across  the  back  of 
the  lower  third  of  the  forearm.  This  swelling  shows  distinct  evidences 
of  fluctuation  and  is  the  result  of  accumulation  of  fiuid  within  the  sheath, 

(b)  An  acute  primary  serofibrinous  tenosyjwvilis  occurs  in  the  flexor 
sheaths  of  the  fingers,  and  can  be  recognized  from  the  location  of  the  pain 
and  the  fullness  over  the  normal  depressions  at  the  folds  of  the  fingers. 
The  latter  are  held  rigid,  and  only  the  terminal  phalanx  can  be  flexed. 
This  form  is  a  not  infrequent  sequel  of  fractures  or  other  conditions  in 
which  the  fingers  arc  kept  immobilized. 


568  THE   EXTREMITIES. 

(c)  Acute  Primary  Sero purulent  Tenosynovitis. — This  also  affects  the 
flexor  sheaths  of  the  fmgers.  It  shows  the  same  local  signs  as  the  pre- 
ceding form,  but  there  is  higher  fever  and  more  pain. 

Acute  Secondary  Tenovaginitis  or  Tenosynovitis. — The  acute 
secondary  forms  are  due  either  to  (a)  infection  from  neighboring 
tissues  extending  through  the  sheath;  (b)  to  gonorrheal  metastasis, 
or  (c)  occur  as  a  complication  of  syphilis  during  the  period  of  the  first  skin 
eruption.  Suppurative  tenosynovitis,  which  is  secondary  to  infection 
of  the  surrounding  tissues,  as  in  infected  fmgers,  or  occurs  after  pene- 
trating wounds  of  the  sheaths,  has  been  previously  referred  to.  The 
diagnosis  of  the  acute  gonorrheal  and  syphilitic  varieties  can  be 
made  as  in  the  other  forms  by  the  occurrence  of  pain  and  swelling  along 
the  course  of  tendon-sheaths,  accompanied  by  loss  of  function.  In 
addition  to  these  two  signs  there  is  usually  more  or  less  redness  of  the 
overlying  skin. 

All  of  the  above-described  forms,  with  the  exception  of  the  acute 
crepitating,  affect  the  extensor  and  flexor  sheaths  of  the  hand  and 
fingers,  as  well  as  those  around  the  ankle  (peronei,  extensors,  tibialis 
anticus  and  posticus). .  Involvement  of  the  sheaths  of  the  biceps 
brachii  and  of  the  flexors  of  the  knee  occurs  less  frequently.  In  the 
gonorrheal  form  the  condition  usually  occurs  when  the  urethritis  has 
existed  for  some  time. 

Chronic  Tenosynovitis. — (a)  Chronic  Serous  Tenosynovitis. — • 
This  may  be  a  sequela  of  the  acute  crepitating  form,  or  it  may  follow  exces- 
sive use  of  the  hands  or  feet.  In  the  case  of  the  fingers,  it  occurs  in 
painters,  engravers,  artists,  etc.  The  diagnosis  can  be  made  from  the 
swelling  corresponding  accurately  either  to  the  extensor  (Figs.  391 
and  392)  or  flexor  sheaths.  The  sheath  (a)  may  contain  simply  serum 
and  the  serous  fining  show  but  little  change,  or  (b)  it  may  contain 
many  rice-like  bodies  (corpora  oryzidae)  with  marked  papillomatous 
excrescences  in  the  sheath  wall. 

(b)  Tuberculous  Tenosynovitis. — This  forrn  of  chronic  inflammation 
of  the  tendon-sheaths  most  frequently  affects  the  flexors  of  the  hand, 
less  often  the  sheaths  around  the  ankle.  There  are  several  clinical 
forms  whose  recognition  is  important.  The  first  variety  is  one  in  which 
there  is  a  well-marked  oblong  swelling,  corresponding  in  outline  to 
the  tendon-sheaths,  over  which  there  is  distinct  fluctuation,  and  con- 
taining many  rice  bodies.  These  rice  bodies  can  often  be  distinctly  felt 
and  pushed  through  constrictions  in  the  sac.  Perforation  may  occur  with 
discharge  of  caseous  material.  In  the  second  variety  the  tendon- 
sheath  is  greatly  thickened,  so  that  more  or  less  sohd  tumors  are  formed 


DISEASES    OF   THE    TENDONS    AND   TENDON- SHEATHS. 


569 


corresponding  in  outline  to  the  sheaths.     In  both  of  these  tuberculous 
forms  the  diagnosis  is  not  difficult  if  there  are  evidences  of  tuberculosis 


Fig.  391 . — Lateral  View  of  Case  of  Tenosynovitis  of  Extensor  Tendon-sheaths  on  Dorsum  of  Hand. 


Fig.  392. — Direct  View  of  Samf.  Cask  as  shown  in  Fig.  391,  showing  the  Swelling  in  the  Middle  of 
the  Dorsum  of  the  Hand  due  to  Tenosynovitis  of  the  F.xtensor  Tendon-sheaths  of  the  Fingers. 


elsewhere.  But  if  such  a  liistory  is  al)^^nl,  sus])icion  sliould  be  aroused 
by  the  chronicity  of  the  process  and  the  clinical  signs  of  one  of  these- 
two  forms. 


570 


THE   EXTREMITIES. 


(c)  Chronic  Syphilitic  Tenosynovitis. — The  acute  form  has  been 
referred  to  above.  Both  the  acute  and  chronic  varieties  are  more 
frequently  found  in  women  and  affect  the  extensors  of  the  fingers  and 
toes,  the  biceps,  and  peroneus  sheaths.  In  the  chronic  form  there 
may  occur  a  simple  exudation  into  the  sheath,  or  a  gummatous  nodu- 
lated infiltration  of  the  same.  The  diagnosis  is  very  difficult  unless 
there  is  a  distinct  history  of  syphihs  and  the  condition  clears  up  after 
the  use  of  antisyphilitic  treatment. 

Tumors  of  Tendons  and  Tendon-sheaths. — lipoma  arbores- 
cens  and  sarcoma  constitute  practically  the  only  forms  of  neoplasms. 
The  former  occurs  in  a  symmetrical  manner  in  the  flexor  sheaths  of 
the  hand,  forming  a  soft  semifluctuating  tumor  which  can  scarcely 
be  distinguished  from  tuberculous  inflammation.  The  most  common 
forms  of  mahgnant  tumors  are  the  fibrosarcomata.  They  are  observed 
both  in  young  and   old   people.     Their  growth  is   slow  and   usually 

painless.  They  are 
hard  and  are  situ- 
ated on  the  flexor 
side. 

Ganglion.  —  It 
seems  appropriate 
to  refer  here  to  a 
tumor  which  is 
usually  found  upon 
the  dorsum  of  the 
wrist. 

A  second  typical  location  is  upon  the  flexor  surface  of  the  wrist  or 
fingers.  The  tumors  vary  in  size  from  a  cherry  to  that  of  a  walnut. 
If  they  he  deeply  they  are  quite  hard,  but  if  they  are  superficial,  they 
fluctuate.  A  diagnosis  is  not  difficult  on  account  of  their  pnsistency 
and  location.  They  can  best  be  seen  when  the  wrist  is  fully  extended 
or  flexed,  according  to  which  side  of  the  wrist  they  are  located 
upon.  Many  communicate  with  the  wrist-joint  and  are  a  form  of  hernia 
of  the  joint.  According  to  Ledderhose  and  Ritschl,  others  are  simply 
the  result  of  a  colloid  degeneration  of  connective  tissue. 


Fig.  393. — Ganglion  on  the  Back  of  the  Wrist  ("  International  Text 
Book  of  Surgery  ")• 


DISEASES  OF  MUSCLES. 
Inflammatory  Affections. 
I.  Acute    Muscular    Rheumatism    {Acute    Serous    Myositis). — 
This  is  only  mentioned  in  a  surgical   book  to   call  attention  to  the 


DISEASES    OF   MUSCLES.  57I 

fact  that  it  may  occur  suddenly  after  muscular  exertion  and  simu- 
late a  more  serious  condition.  In  addition  to  the  severe  pain,  there  is 
rigidity  of  the  hmb  or  joint  which  is  moved  by  the  affected  muscle,  as 
well  as  well-marked  local  tenderness.  The  affection  yields  rapidly  to 
antirheumatic  treatment. 

2.  Acute  Suppurative  Myositis. — This  is  almost  invariably  sec- 
ondary to  a  neighboring  focus  of  suppuration,  but  may  occur  quite 
rarely,  as  a  primary  form.  In  the  latter  there  are  manifest  local  dis- 
turbances, such  as  marked  swelling  and  pain  over  the  affected  muscle, 
followed  by  edema  and  induration  of  the  overlying  sldn  with  subsequent 
fluctuation. 

3.  Simple  Chronic  or  Fibrous  Myositis  {Sclerosing  Myositis). — 
This  may  follow  {a)  an  attack  of  rheumatic  myositis;  {h)  trichinosis; 
(c)  thrombosis  of  the  vessels  of  an  extremity,  or  {d)  the  long- continued 
or  too  tight  application  of  bandages,  casts,  etc. 

In  all  of  these  there  is  overgrowth  of  the  interstitial  tissue  with 
atrophy  of  muscle  fibers.  The  muscle  itself  feels  hard  and  atrophic. 
Contractures  and  loss  of  function  usually  result.  After  fractures, 
especially  where  the  splints  have  been  employed  for  a  long  period  or 
the  dressing  was  applied  too  tightly,  this  form  is  especially  common. 
The  condition  is  called  ischemic  muscular  contracture  or  paralysis. 

4.  Myositis  Ossificans. — This  occurs  most  often  in  a  locaHzed 
form,  but  may  rarely  be  quite  generahzed. 

The  formation  of  bone  in  the  intermuscular  tissue  may  occur  as 
the  result  of  either  a  single  or  frequently  repeated  trauma.  The  most 
frequent  location  is  in  the  adductors  of  the  thigh,  as  the  so-called  rider's 
bone,  or  in  the  deltoid  and  pectoralis  major  muscles.  As  a  more  general 
disease  it  occurs  either  without  apparent  cause  or  after  an  injury.  The 
idiopathic  form  affects  chiefly  the  muscles  of  the  back  and  spine.  This 
ossification  may  follow  a  complex  of  symptoms,  such  as  high  fever, 
swelling,  and  pain  in  the  muscle.  These  recur  from  time  to  time, 
and  after  the  attack  has  passed  away,  hard  nodules  are  to  be  felt  in  the 
muscle.  Every  muscle  in  the -body  may  be  involved,  with  the  excep- 
tion of  those  of  the  face.  Only  forty  cases  of  this  generalized  form 
have  thus  far  been  reported.  The  diagnosis  is  confirmed  by  the  use 
of  the  .X'-ray. 

5.  Tuberculous  myositis  is  usually  scconchiry  to  bone  or  Ivmph- 
node  foci  in  the  A'icinil}'  or  may  occur  after  an  injun-,  if  there  are  foci 
elsewhere.  Quite  rarely  multiple  tuljcrculous  al^scesses  are  found  in  a 
muscle  without  any  neighboring  focus. 

6.  Syphilitic   Myositis. — This  occurs  either  {a)  as  an  inliltrating 


572  THE    EXTREMITIES. 

myositis  which  begins  as  a  muscular  rheumatism  and  causes  the  mus- 
cle to  become  rigid  and  nodular,  or  (b)  as  a  gumma  close  to  the 
tendon  or  in  the  belly  of  the  muscle,  affecting  most  often  the  sterno- 
cleidomastoid and  the  muscles  of  mastication.  They  form  hard  nod- 
ules which  are  usually  painless.  They  may  attain  the  size  of  an  apple. 
At  times  they  undergo  softening  and  discharge,  their  contents  leaving 
an  ulcer  with  serpentine  outline  and  steep  edges.  The  diagnosis  is  not 
difficult  if  there  is  a  distinct  history  of  syphilis,  either  congenital  or 
acquired.  They  must  only  be  differentiated  from  echinococcus,  since 
fev/  other  tumors  occur  in  a  muscle.  The  nodules  disappear  rapidly 
after  the  use  of  antisyphihtic  treatment. 


Fig.  394. — Fascial  Sarcoma  of  Calf  of  Leg. 
The  arrow  points  to  the  prominence  caused  by  the  soft  semifluctuant  sarcoma. 


Tumors  of  Muscles, 

Primary  tumors  are  rare.  These  are  usually  hemangiomata,  lymph- 
angiomata,  or  sarcomata.  Desmoids  occurring  in  the  muscles  of  the 
abdominal  wall  were  previously  described  (page  234).  Angiomata 
are  of  slow  formation,  extending  over  a  period  of  years.  In  rare  cases 
they  grow  within  a  few  months.  They  feel  like  a  lipoma  and  are  not 
always  compressible.     They  occur  most  frequently  in  young  persons. 

Sarcoma  may  arise  in  muscle  as  a  primary  tumor.  It  causes  rapid 
enlargement  of  the  part,  feels  c|uite  firm,  and  is  painless  (see  Fig.  394). 

Hydatid  Cysts  in  Muscles. — These  occur  quite  often  in  muscles 


DISEASES    OF   THE    FASCLE — DISEASES    OF   THE    NERVES.  573 

(about  two  per  cent,  of  all  cases).  They  can  be  differentiated  from 
gummata  by  their  more  elastic  consistency.  The  diagnosis  of  a 
hydatid  cyst  is  seldom  made  before  operation. 

DISEASES  OF  THE  FASCIA. 
Dupuytren's  Contraction, — In  both  young  and  old  persons  a 
contraction  of  the  palmar  fascia  occurs,  causing  a  flexion  of  one  or 
more  fingers.  It  usually  affects  the  ring-  and  little  fingers,  but  may 
involve  the  index-  and  middle  fingers.  In  the  palm  of  the  hand,  one 
can  see  and  feel  one  or  more  firm  bands  to  which  the  skin  is  adherent. 
The  skin  is  also  thrown  into  transverse  folds  and  depressions.  The 
flexion  of  the  fingers  may  be  very  slight,  or  it  may  be  so  marked  that 
the  tip  of  the  finger  almost  touches  the  palm  of  the  hand  (Fig.  260). 
The  position  of  the  hand  has  been  hkened  to  that  in  which  it  is  held 
during  benediction.  The  clinical  picture  is  so  typical  that  the  diag- 
nosis is  easy.  The  only  differentiation  is  from  contraction  of  the  fin- 
gers following  opening  of  the  tendon-sheath,  as  a  result  of  injury  (Fig. 
260),  or  intentionally  during  the  treatment  of  a  suppurative  tenosyn- 
ovitis. Under  these  latter  conditions  one  feels  a  single  longitudinal 
band  or  cord,  and  the  skin  of  the  palm  is  only  adherent  to  it.  There 
is  absence  of  the  transverse  folds  and  depressions,  as  well  as  of  the 
nodules  seen  in  a  Dupuytren's  contraction. 

DISEASES  OF  THE  NERVES. 
Neuritis. — From  a  surgical  standpoint   great  interest  is  attached 
to  this  condition  of  inflammation  of  a  nerve-trunk.     Its  local  causes  are : 

1.  Pressure  of  a  tumor  or  aneurysm  upon  the  nerve,  either  close 
to  its  point  of  exit  from  the  spinal  canal  or  somewhere  along  its  course. 

2.  The  nerve  may  be  involved  by  extension  from  a  neighboring 
septic  focus. 

3.  As  a  complication  of  nerve  injury.  Neuritis  is  much  more  apt 
to  develop  after  an  incomplete  division  of  a  nerve  (by  a  knife,  glass, 
or  a  bullet)  than  after  a  complete  severing  of  its  continuity. 

4.  As  a  complication  of  fractures  or  dislocations.  In  the  former 
the  nerve  may  be  caught  between  the  fragments  or  be  pressed  upon  by 
the  callus.  In  an  unreduced  dislocation  the  displaced  head  of  the  bone 
may  compress  the  contiguous  nerve-trunks. 

5.  Neuritis  may  follow  temporary  pressure  upon  or  contusion  of 
a  nerve  without  any  external  signs  of  injury.  The  neuritis  following 
too  light  an  application  of  a  constrictor  is  an  example  of  this  form. 


574  THE    EXTREMITIES. 

Neuritis  may  present  itself  clinically  in  either  an  acute  or  a  chronic 
form,  or  the  latter  may  develop  from  the  former.  The  diagnosis  of  the 
presence  of  a  neuritis  may  be  made  from  the  following  signs : 

{a)  Pain.  This  is  of  a  boring  character  and  continuous,  not  inter- 
mittent as  in  a  neuralgia.  The  pain  is  felt  along  the  course  of  the  nerve 
and  is  increased  by  pressure  upon  the  nerve  or  by  movements  of  the  hmb. 

{h)  Sensory  changes.  At  first  all  forms  of  paresthesia  are  com- 
plained of,  viz.,  numbness,  burning,  coldness,  etc.  There  is  weakness 
or  paresis  of  the  muscles  supplied  by  the  affected  nerve. 

(c)  Trophic  changes.  There  is  early  wasting  or  atrophy  of  the 
muscles  involved.  The  skin  becomes  glazed,  the  nails  rough  and 
curved,  and  the  limb  feels  colder  and  looks  bluish.  Bullae  and  ulcers 
may  appear  on  the  skin. 

{d)  Electrical  changes.  If  the  nerve  has  not  been  completely  divided 
the  reaction  of  degeneration  is  present  three  to  four  weeks  after  the 
injury.  If  the  nerve  has  been  totally  destroyed  by  the  injury  or  com- 
pression there  is  absence  of  all  kinds  of  electrical  responses. 

{e)  The  muscle  reflexes  are  lost  and  there  are  secondary  contractures 
due  to  the  action  of  the  antagonistic  muscles.  If  the  nerve  degenera- 
tion becomes  complete  there  is  complete  anesthesia  in  the  area  of  skin 
supplied  by  it  and  also  total  paralysis  of  the  affected  muscles.  This 
condition  is,  however,  infrequent,  except  after  complete  division  of  a 
nerve.  The  fact  that  the  neighboring  nerves  may  assume  some  of 
the  cutaneous  sensory  distribution  must  not  be  forgotten. 

A  neuritis  can  be  distingushed  from  a  neuralgia  by  the  facts  that 
in  the  latter  (a)  the  pain  is  intermittent  and  not  continuous  as  in  a 
neuritis.  (&)  There  is  an  absence  of  pain  along  the  nerve-trunk  and 
of  tenderness  over  the  paretic  muscles,  (c)  In  neuralgia  there  is  no 
paresis  or  paralysis  of  muscles,  nor  loss  of  muscle  reiiexes.  {d)  There 
are  also  non-trophic  or  sensory  disturbances  and  no  changes  in  the 
electrical  responses. 

Tumors  of  the  Nerves. — Chnically,  there  are  three  forms  of 
nerve  tumors:  (a)  Traumatic  neuromata;  {h)  neuroma  dolorosa,  or 
painful  subcutaneous  tubercle;    (c)  multiple  neuromata. 

Traumatic  neuromata  develop  from  the  cut  ends  of  a  di^'ided 
nerve.  They  form  an  extremely  sensitive  palpable  nodule  on  the  end 
of  the  nerve  in  an  amputation  stump,  or  wherever  the  nerve  chances 
to  have  been  severed. 

Neuromata  dolorosa,  also  called  painful  subcutaneous  tubercles, 
are  easily  felt  just  beneath  the  skin,  and  cause  pain  and  tinghng  in 
the  area  of  cutaneous  distribution  of  the  nerve. 


DISEASES    OF   THE    BONES.  575 

Multiple  Neuromata. — These  have  also  been  termed  plexiform 
neuromata  and  are  often  congenital.  They  seldom  cause  symptoms 
and  are  only  to  be  diagnosed  by  the  often  visible,  but  more  frequently 
palpable,  series  of  nodules  along  the  nerve-trunks.  They  are  found 
chnically  in  three  forms:  (a)  As  bead-like  enlargements  at  regular 
intervals  along  a  single  or  several  nerve-trunks;  {h)  only  on  a  single 
nerve,  when  the  symptoms  of  neuritis  may  be  present  and  must  be 
differentiated  from  those  due  to  pressure  from  other  causes;  (c)  invad- 
ing nearly  every  nerve  in  the  body. 

DISEASES  OF  THE  BONES. 

For  diagnostic  purposes  affections  of  the  bones  are  best  divided 
into  the  acute  and  the  chronic.  The  majority  of  both  of  these  clinical 
groups  are  due  to  infective  microorganisms.  A  small  percentage  of 
the  chronic  forms  are  the  result  of  disturbances  in  metabohsm. 

The  following  will  be  found  to  be  a  very  useful  classification : 

I.  Acute  Diseases  of  Bone. 

1.  Those  involving  the  periosteum  chiefly. 

{a)  x\cute  traumatic  periostitis. 

ih)  Acute  infective  periostitis — usually  secondary  to  acute 

infective  osteomyelitis,  but  the  periosteum  alone  may 

be  involved  in  some  cases, 
(c)  Acute    syphilitic    periostitis.     Painful    nodes    in    early 

portion  of  secondary  stage  (see  page  589). 
{d)  Chronic    syphilitic    or    tubercular    periostitis — usually 

secondary  to   same  disease  of  medulla,   but   may  be 

confined  to  the  periosteum  in  late  secondary  or  early 

tertiary  syphilis  (see  page  589). 

2.  Those  involving  the  medulla  primarily. 

{a)  Acute  infective  or  suppurative  osteomyelitis. 

(6)  As  a  complication  of  compound  fractures,  of  amputa- 
tions, or  of  operations  on  bones. 

(c)  As  a  primary  disease,  i.  e.,  the  ordinary  type  of  acute 
infective  or  suppurative  osteomyelitis.  Most  frequently 
due  to  the  staphylococcus  pyogenes  aureus  and  albus, 
and,  rarely  to  the  streptococcus  pyogenes,  pneumo- 
coccus,  and  typhoid  bacillus. 
11.  Chronic  diseases  of  hone,i.  e.,  those  whicli  arc  ])nmarily  chronic. 
I.  Those  due  to  infective  agents. 

(a)  Due  to  the  tubercle  bacillus;    most  frequent  scat  is  in 
epiphysis  or  in  shaft  close  to  epiphyseal  cartilage  in 


576  THE    EXTREMITIES. 

long  pipe  bones.     Frequent  in  shaft  of  metacarpals, 
metatarsals,  phalanges,  tarsal  and  carpal  bones. 
(b)  Syphilitic  periostitis  and  osteomyelitis. 
2.  Bone  diseases  due  to  retrograde  disturbances  of  nutrition. 

(a)  Osteomalacia. 

(b)  Rachitis. 

(c)  Barlow's  disease. 

(d)  Acromegaly. 

(e)  Osteoarthropathie  pneumatique  of  ]\Iarie. 
(/)  Osteitis  deformans  of  Paget. 

(g)  Phosphorus  necrosis. 

The  majority  of  acute  and  chronic  diseases  of  the  bones  occur 
during  infancy  and  youth.  Tliis  is  especially  true  of  acute  infective 
osteomyelitis  and  of  tuberculosis  of  bone.  Lexer  ^  has  demonstrated 
this  to  be  due  to  the  fact  that  emboli  composed  of  clumps  of  bacteria, 
originating  from  a  primarv'  focus  in  some  other  part  of  the  body,  are 
carried  to  the  bone  through  the  circulation.  The  long  and  short  pipe 
bones  of  the  extremities  receive  their  arterial  supply  from  three  sources 
(see  Fig.  395),  viz.:  (c)  A  diaphyseal  group  of  vessels,  v^'hich  extend 
through  the  shaft  in  both  directions  almost  to  the  epiphyseal  hne  and 
end  here  as  terminal  arteries.  These  gradually  become  smaller  Avith 
advancing  age.  (b)  A  metaphyseal  group,  which  enter  the  shaft  near 
the  epiphyseal  Une  and  branch  in  the  direction  of  the  epiphysis,  fre- 
quently perforate  the  epiphyseal  cartilage,  and  end  as  terminal  arteries 
in  the  epiphysis.  These  are  the  most  important  in  relation  to  the 
localization  of  pyogenic  or  tuberculous  infections  in  bone,  since  the 
majority  of  these  are  located  close  to  the  epiphyseal  cartilage  either 
on  the  diapliyseal  or  epiphyseal  side,  (c)  The  third  or  epiphyseal 
group  of  vessels  enter  the  epiphysis  from  all  sides  and  run  toward 
the  bone  nucleus.  Some,  however,  extend  to  the  joint,  while  others 
pass  in  the  direction  of  the  epiphyseal  cartilage. 

In  the  diagnosis  of  the  nature  of  any  bone  affection  a  knowledge 
of  the  above  anatomic  facts  will  be  of  great  value.  In  the  long  bones 
of  the  extremities,  the  jociis  of  infection  is  almost  invariably  in  or  near 
the  epiphyses,  because  the '  terminals  of  all  three  groups  of  arteries 
are  located  here.  In  the  short  pipe  bones,  like  the  metacarpals,  meta- 
tarsals, and  phalanges,  the  diaphyseal  vessels  are  large  and  the  meta- 
physeal and  epiphyseal,  narrow.  Hence,  affections  of  these  bones  most 
frequently  involve  the  shaft,  as  is  seen  in  the  case  of  a  spina  ventosa  or 
tuberculous  dactylitis  (Fig.  399). 

^  Lexer:  "  Archiv  fiir  klinische  Chirurgie,"  vols.  Ixxi  and  Ixxiii. 


DISEASES    OF   THE    BOXES. 


577 


FrankeP  has  shown  that  organisms  lodge  in  the  medulla  of  the 
bones  in  all  of  the  infectious  diseases.     They  may  cause  no  symptoms 
or  remain  latent  for  many  years,  and  then  suddenly  be  awakened  into 
activity  through  some  slight 
trauma.     In  general  the  fol- 
lowing may    be   said  of  the 
two   most    frequent    inflam- 
matory diseases  of  bone : 

1.  Acute  suppurative  os- 
teomyelitis most  frequently  af- 
fects the  shaft  of  the  long  bones 
of  the  extremities.  Less 
often  does  it  start  in  the  epi- 
physis as  an  epiphysitis  (see 
page  579),  and  rarely  it  in- 
vades the  neighboring  joints  at 
the  beginning  of  the  disease. 

2.  Tuberculosis  of  the 
bones  of  the  extremities  is 
most  frequently  found  close 
to  the  epiphyseal  cartilage  in 
the  shaft  or  in  the  epiphysis 
itself.  In  those  bones  like 
the  upper  end  of  the  femur 
(hip-joint),  where  the  epiphy- 
seal cartilage  hes  within  the 
joint  capsule,  it  involves  the 
joint  primarily.  In  the  other 
bones  the  joints  are  far  more 
often  involved  than  in  acute 
suppurative  osteomyelitis.  In 

young  persons  such  a  primar}'  tuberculosis  of  bone  with  a  complicating 
secondary  tuberculous  arthritis -is  almost  the  rule,  while  in  adults  it  is 
the  exception,  the  joint  disease  being  the  primary  focus. 

I.  Acute  Diseases  of  Bone. 

I.   THOSE  INVOLVING  THE  PERIOSTEUM  CHIEFLY. 

Acute  Traumatic  Periostitis. 
This  follows  a  blow  or  a  fall  upon  the  bone.     It  occurs  most  fre- 
quently in  bones  like  the  tibia  and  the  lower  end  of  the  fibula,  olecranon 

*  "Mittheilungen  aus  den  Grenzgebietcn  der  inncren  Mcdizin  und  Chirurgie,"  vol.  xii. 
37 


Fig.  395. — Localization  of  Bone  Disease  (modified  from 
Lexer). 
I,  Normal  bone.  The  three  sets  of  arteries  which  every 
long  pipe  bone  possseses  are  shown  as  E,  epiphyseal;  M, 
metaphyseal;  and  D,  diaphyseal.  2,  Localization  of  tuber- 
culosis. Involvement  of  the  shaft  is  quite  rare  (see  text). 
MT,  Focus  near  epiphyseal  line  as  a  result  of  plugging  of 
metaphyseal  vessel;  ET,  epiphyseal  focus.  3,  Localization 
of  pyogenic  osteomyelitis.  Involvement  of  shaft  in  majority 
of  cases.  MO,  Metaphyseal  focus;  EG,  epiphyseal  focus. 
The  black  arrows  show  the  direction  in  which  the  pus  may 
spread  from  the  metaphyseal  and  epiphyseal  foci  into  the 
adjacent  joints  or  toward  the  skin. 


578  THE   EXTREMITIES. 

process,  etc.  If  the  bone  lies  superficially,  as  is  the  case  in  the  three 
locations  just  named,  a  swelling  can  be  distinctly  felt  upon  passing  the 
finger  lightly  over  the  bone.  The  swelling  feels  quite  firm  and  is  very 
sensitive  to  the  touch.  The  patient  usually  complains  of  severe  pain 
at  this  point. 

The  course  of  such  a  contusion  of  the  periosteum  varies.     It  may 

(a)  undergo  resolution,  so  that  the  indurated  area  gradually  disappears ; 

(b)  it  may  become  softer  and  show  distinct  fluctuation,  and  this  mass 
becomes  slowly  absorbed,  or  (c)  suppuration  may  occur  even  without 
any  external  wound  being  present.  If  this  latter  change  occurs,  the 
indurated  area  becomes  softer  and  fluctuates.  This  latter  change  is 
accompanied  by  inflammatory  symptoms.  The  periosteal  area  becomes 
extremely  tender  and  painful,  the  skin  over  it  is  red  and  swollen,  and, 
if  the  abscess  is  not  opened,  it  will  discharge  spontaneously,  pus  and 
serum  being  evacuated.  In  some  cases  superficial  necrosis  of  the 
underlying  bone  occurs,  small  sequestra  being  separated  in  five  to  six 
weeks. 

Acute  Infective  Periostitis. 

This  is  rarely  a  primary  process,  and  if  so  is  quite  hmited  in  extent. 
It  occurs  as  a  primary  affection  as  the  result  of  infection  from  neigh- 
boring tissues,  e.  g.,  in  the  jaws  by  extension  from  a  carious  tooth,  in 
the  phalanges  as  a  comphcation  of  infection  of  the  fingers  or  toes. 
On  the  fingers  such  a  suppurative  periostitis,  resulting  in  necrosis  of 
the  underlying  bone,  is  called  a  "felon."  The  periosteum  is  not  infre- 
quently involved  through  extension  of  phlegmonous  processes. 

The  diagnosis  of  such  a  suppurative  periostitis  cannot  often  be 
made  until  a  sinus  has  formed,  leading  to  necrotic  bone.  In  the  early 
stages  there  is  severe  pain  and  tenderness  on  pressure,  well  localized 
over  the  point  of  involvement.  In  superficial  bones  Hke  the  jaw  or 
tibia  there  is  a  swelling  of  the  periosteum  which  may  fluctuate,  and 
after  discharging  pus  one  can  feel  the  exposed  bone  with  a  probe,  and 
after  one  to  two  months  sequestra  separate  and  can  be  extracted. 


2,    THOSE  INVOLVING  THE  MEDULLA  PRIMARILY. 

Acute  Infective  or  Suppurative  Osteomyelitis. 
This  occurs  most  often  in  young  persons  and  may  appear  in  a  sin- 
gle bone  or  in  several  simultaneously.     It  is  a  disease  which  almost 
invariably  begins  in  the  shaft,  and  may  involve  the  adjacent  joints  sec- 
ondarily.    It  is  very  rare  after  complete  ossification  of  the  epiphysis. 


DISEASES    OF   THE    BONES.  579 

When  it  occurs  in  adults,  it  is  usually  the  result  of  the  awakening  into 
activity  of  a  previously  existing  osteomyelitic  focus.  The  tibia  and  femur 
are  more  often  the  seat  of  the  disease  than  any  other  bones  of  the  extrem- 
ities. Next  in  order  of  involvement  are  the  humerus,  radius,  fibula, 
ulna,  and  pelvis.  The  number  of  cases  in  the  different  years  of  early 
life  gradually  rises  to  the  tenth  year,  and  is  highest  at  the  seventeenth 
year.  The  greatest  number  of  cases  occur  between  ten  and  seven- 
teen years.  After  seventeen  years  the  number  rapidly  decreases,  and 
after  twenty  years  the  number  of  cases  is  few  (TrendeP). 

The  organism  most  frequently  concerned  is  the  staphylococcus 
pyogenes  aureus.  There  are  undoubtedly  cases  of  acute  osteomye- 
litis which  are  due  to  other  organisms. 

To  this  latter  class  belong  those  which  are  caused  by  (a)  the  strep- 
tococcus pyogenes;  (b)  the  typhoid  bacillus,  and  (c)  the  pneumococcus. 
It  is  almost  impossible  clinically  to  distinguish  an  osteomyehtis  due  to 
these  three  organisms  from  that  caused  by  the  staphylococcus  pyogenes 
aureus.  Lexer  and  Klemm  have  shown  that  there  is  but  little  differ- 
ence, from  either  a  clinical  or  pathologic  standpoint.  One  may,  how- 
ever, find  an  infection  atrium,  such  as  an  infected  streptococcus  wound, 
a  pneumonia,  an  otitis  media,  a  pharyngitis  of  some  kind,  an  infected 
umbilicus,  etc.  There  is  also  apt  to  be  more  edema  of  the  soft  parts, 
especially  in  the  streptococcus  variety.  A  widespread  phlegmon  of  the 
shaft  is  rare  in  both  of  these  forms,  as  well  as  in  that  due  to  the  typhoid 
bacillus.     The  focus  is  usually  quite  localized  and  often  subperiosteal. 

The  diagnosis  of  the  ordinary  form  of  acute  suppurative  osteo- 
myelitis is,  as  a  rule,  not  difficult.  There  arc,  however,  three  distinct 
clinical  types: 

1.  It  may  begin  suddenly  with  swelHng  over  the  affected  bone,  de- 
lirium, high  fever,  leukocytosis,  rapid  pulse,  and  other  signs  of  a  severe 
septic  intoxication,  death  occurring  in  a  few  days. 

2.  It  may  appear  as  a  so-called  acute  arthritis  in  infants  from  three 
Weeks  to  two  years  of  age.  The  onset  is  sudden,  tliere  is  marked  rise 
of  temperature,  rapid  pulse,  and  other  signs  of  septic  intoxication. 
The  joint  is  swollen  and  very  painful.  The  local  swelling  may  be 
followed  by  pus  formation,  which  is  often  evacuated  spontaneously. 
In  the  severer  cases  separation  of  the  e])iphysis  occurs  with  disorgan- 
ization of  the  joint.  It  has  been  clearl}'  shoAMi  that  these  cases  of  ani/r 
septic  arthritis  in  infants  and  young  children  are  the  result  of  a  rup- 
ture into  the  joint  of  an  osteomyelitic  focus  situated  on  the  shaft  side 
of  the  epiphyseal  cartilage.     The  suppurative  arthritis,  whicli  is  the 

'  "Beitragc  zur  klinischen  Chirurgie,"  vol.  .\li. 


THE    EXTREMITIES. 


most  prominent  clinical  symptom,  is  due  (a)  to  the  fact  that  (as  in  the 
hip)  the  epiphyseal  cartilage  lies  within  the  joint,  or  (b)  that  the  focus 
ruptures  into  the  joint  cavity,  or  (c)  it  burrows  through  the  epiphysis 
and  then  invades  the  joint.  To  this  form  of  the  disease  the  name 
epiphysitis  has  been  given  in  England. 

3.  The  ordinary  clinical  form  of  acute  suppurative  or  infective  osteo- 
myelitis may  arise  as  (a)  a  complication  of  compound  fractures,  of 
amputations,  or  operations  on  bones,  or  (b)  it  may  follow  a  slight  trauma 
or  exposure  to  cold  or  wet,  or  (c)  develop  in  the  course  of  an  infectious 

disease  like  pneumonia,  t}^hoid, 
scarlatina,  variola,  etc.  The  clini- 
cal history  is  as  follows :  The  dis- 
ease begins  suddenly  with  severe 
pain  and  tenderness  over  the  af- 
fected bone,  usually  of  the  shaft, 
or  over  several  bones,  if  multiple 
foci  exist.  A  chill  often  ushers 
in  the  disease,  followed  by  high 
fever.  The  temperature  curve  re- 
sembles greatly  that  of  a  typhoid, 
being  of  a  continuous  type.  The 
limb  soon  becomes  swollen,  ten- 
der, and  indurated.  The  skin 
glistens,  is  red,  and  feels  hot. 
There  is  rigidity  of  the  adjacent 
joints.  If  no  surgical  rehef  is 
given  one  of  two  conditions  results : 
^     "'"^^i^ll^g^'"*  u^  {a)  A  septicemia   develops  with 

'       '  '  high  fever  of  a  continuous  type, 

rapid  pulse,  dr}'-coated  tongue, 
marked  leukocytosis,  dehrium  or 
stupor,  sweats,  and  diarrhea. 
ijo)  In  less  severe  cases  the  pus  perforates  the  cortical  portion  of  the 
shaft  and  the  periosteum,  and  appears  beneath  the  skin  as  an  abscess 
with  distinct  fluctuation.  The  patient  may  present  himself  with  a 
sinus  leading  to  necrotic  bone  in  the  shaft  and  give  a  history  of  such  an 
acute  onset  as  just  described. 

If  the  medulla  has  not  been  sufficiently  drained,  the  septic  symp- 
toms may  persist.  The  fever  shows  a  distinct  rise  in  the  evening  (hec- 
tic type)  with  morning  remissions.  The  limb  remains  bra^\^ly  and 
swollen,  and  considerable  pus  continues  to  be  discharged  from  the  wound 


Fig.   396. — Acute   Osteomyeliti: 
(Nichols). 


OF   THE    Tibia 


DISEASES    OF   THE    BONES. 


581 


of  operation  or  sinus.     An  x-my  picture  will  often  be  of  great  aid  in 
the  diagnosis  of  the  presence  of  sequestra. 

A  chronic  conchtion  may  result  from  an  acute  osteomyelitis  and 
last  for  forty  to  fifty  years.  The  sinus  leading  to  the  original  focus 
may  heal  and  then  after  years  an  acute  exacerbation  may  supervene. 
The  diagnosis  in  such  cases  can  be  made  from  the  previous  history, 
the  presence  of  a  scar  over  the  shaft,  and  the  local  inflammatory  signs. 

In  some  cases  an  encapsulated  abscess  may  exist  for  many  years. 
It  has  been  called  a  chronic 
bone  abscess.  The  diag- 
nosis in  these  cases  can  be 
made  (a)  from  the  fre- 
quently recurring  pains ; 
(b)  the  evening  rise  of  tem- 
perature, and  (c)  from  the 
presence  of  tenderness  on 
pressure  over  the  bone 
focus. 

Differential  Diagno- 
sis of  Acute  Osteomye- 
litis.— Typhoid  Fever. — 
The  first  clinical  type  of 
acute  osteomyelitis  de- 
scribed above  (see  page 
578)  may  at  first  sight  re- 
semble a  case  of  typhoid. 
The  fever  is  high  and  of  a 
continuous  type,  and  there 
is  stupor  and  delirium  in 
both.  In  acute  osteomye- 
litis, however,  there  is  a 
high  degree  of  leukocyto- 
sis   and    absence    of    tlie 

Widal  test,  unless  the  patient  ha.-,  had  a  recent  typhoid,     in  addition  the 
local  evidences  of  inflammation  can  usually  be  found  by  careful  search. 

Infectious  Arthritis. — The  second  type  of  acute  osteomyeHtis,  in 
which  the  focus  lies  in  or  near  the  epiphysis,  may  greatly  resemble 
arthritis  due  to  other  causes.  This  is  especially  true  of  osteomyelitic 
foci  at  the  upper  and  lower  ends  of  the  femur,  and  tlie  upper  end  of 
the  humerus.  The  symptoms  are  generally  more  severe  both  in  infants 
and  older  children  than  in  an  arthritis  due  to  other  causes.     The  pain, 


Fig.  397. — External  Appearanck  of  I-eft  Thigh  ix  a  Case 
OF  Osteomyelitis  of  the  Femlr. 

The  arrow  points  to  the  swelling  caused  by  the  involucrum  and 
thickening  of  the  subcutaneous  tissue. 


582  THE   EXTREMITIES, 

swelling  about  the  joint,  and  fever  are  very  marked.  Abscess  forma- 
tion follows  in  the  majority  of  the  cases,  and  is  preceded  by  a  high 
degree  of  leukocytosis. 

Epiphyseal  separation  is  quite  common  in  the  cases  of  acute 
osteomyelitis  close  to  a  joint,  and  the  diagnosis  can  often  be  made  from 
the  resultant  deformity  and  the  use  of  the  x-ray. 

In  subacute  cases  it  is  impossible  before  operation  to  make  a  dif- 
ferentiation from  tuberculosis  of  the  joints. 

Tuberculosis  of  Bone. — In  the  acuter  types  of  suppurative  osteo- 
myehtis  there  should  be  no  difficulty  in  making  a  differentiation  from 
tuberculosis.  The  pain,  leukocytosis,  local  sweUing  and  tenderness, 
high  fever,  etc.,  are  all  characteristic  of  an  acute  osteomyehtis. 

There  are  certain  subacute  cases  of  osteomyelitis  which  may  resem- 
ble a  tuberculosis.  There  are,  however,  even  in  these  cases  certain 
points  of  difference.  Tuberculosis  affects  the  shaft  close  to  the  epiphysis, 
or  the  latter  itself,  while  it  is  rare  in  the  shaft  of  the  long  bones.  Acute 
osteomyelitis  is  most  frequently  a  disease  of  the  medulla  of  the  shaft  and 
is  rarely  situated  close  to  the  epiphyses.  The  history  of  pain,  rise  of 
temperature,  and  the  local  signs,  such  as  tenderness  on  pressure,  swell- 
ing, etc.,  are  all  more  marked  in  an  acute  infective  osteomyelitis.  An 
x-ray  will  show  greater  thickening  of  the  bone,  due  to  involucrum  forma- 
tion in  osteomyehtis.  If  a  sinus  exists,  the  granulation-tissue  will  often 
be  of  great  aid  in  making  a  diagnosis,  being  caseous  and  flabby  in 
tuberculosis,  and  if  examined  microscopically,  will  show  giant-cells  and 
tubercles. 

II.  Primarily  Chronic  Diseases  of  Bone. 

J.  THOSE  DUE  TO  INFECTIVE  AGENTS. 

Tuberculosis  of  Bone. — This  may  occur  clinically  in  the  follow- 
ing forms : 

1.  As  single  or  multiple  foci  in  the  epiphyses  of  the  long  pipe  bones, 
e.  g.,  femur,  tibia,  humerus,  ulna,  radius,  fibula,  and  clavicle. 

2.  As  a  tuberculous  osteomyelitis  of  the  short  pipe  bones,  e.  g., 
metatarsals,  metacarpals,  and  phalanges  of  the  toes  and  fingers. 

3.  In  the  spongy  bones  of  the  carpus  and  tarsus. 

4.  In  the  flat  bones,  e.  g.,  pelvis,  scapula,  ribs,  sternum,  and 
skufl. 

A  tuberculous  osteomyehtis  of  the  shaft  or  a  diaphysis  of  the  long 
pipe  bones  is  very  rare.  Nichols  states  that  he  has  been  unable  to 
find  it  in  one  hundred  and  twenty  cases  studied  by  him,  and  Kiittner 
was  only  able  to  discover  six  cases  in  a  total  of  two  thousand  one  hun- 


DISEASES    OF   THE    BONES. 


583 


dred  and  twenty-seven  cases  of  tuberculosis  of  the  bones  and  joints  in 
von  Bruns'  clinic  (0.28  per  cent.). 

The  diagnosis  0}  tuberculosis  of  bone  varies  according  to  its  local- 
ization. 

I.  If  situated  in  the  epiphyseal  ends  of  the  long  pipe  bones, 
the  symptoms  of  the  secondary  joint  affection  may  predominate  to 
such  an  extent  that  a  pri- 
mary bone  focus  is  only  to 
be  suspected  from  the  gener- 
ally accepted  fact  that  in  the 
majority  of  cases  tuberculous 
arthritis  is  secondary  to  a 
primary  bone  focus. 

In  bones  Hke  the  olecranon, 
upper  and  lower  ends  of  the 
tibia,  clavicle,  lower  end  of 
the  femur  or  radius,  which  are 
accessible  to  inspection  and 
palpation,  the  presence  of  a 
tuberculous  focus  may  be 
suspected  from  the  following 
symptoms : 

1.  A  locahzed  tenderness 
and  swelling  (Fig.  398),  ac- 
companied by  moderate  pain 
upon  pressure  or  movement  of 
the  limb.  The  pain  is  never 
acute,  as  in  an  infective  osteo- 
myehtis,  and  there  is  httle 
if  any  rise  of  temperature.  If 
caseation  and  perforation  of 
the  periosteum  have  occurred, 
the  presence  of  fluctuation  and  ' 

the  history  of  slight  pain  preceding  the  appearance  of  the  swelling  ren- 
der the  diagnosis  of  tuberculosis  ])robablc.  This  is  especially  true  if 
such  an  abscess  appears  in  a  child  or  atkilt  at  the  lime  of  examination 
or  at  some  prior  period. 

2.  Tuberculous  osteomyelitis  occurs  chieily  in  the  short  jjipe  bones 
of  the  hands  and  foot,  e.  g.,  metacarpals,  metatarsals,  and  phalanges. 
It  has  been  termed  tuberculous  dactylitis  or  spina  ventosa.  To  some 
extent  the  ulna  resembles  these  sliort  ])ij)C  bones,  in  the  fact  that  tuber- 


FiG.  308. — External  Appearance  of  Thigh  in  a 
Case  of  Osteosarcoma  of  the  Lower  End  of  the 
Femur  Simulating  Tuberculous  Osteomyelitis. 


S84 


THE   EXTREMITIES. 


culous  localization,  if  it  does  not  occur  in  the  olecranon  process,  is 
most  apt  to  take  place  in  the  shaft.  The  short  pipe  bones  of  the  hand 
are  far  more  frequently  involved  than  those  of  the  foot.  The  affected 
bone  is  expanded  and  becomes  spindle-shaped.  This  thickening  of  the 
bone  is  so  marked  as  to  be  distinctly  palpable,  and  can  be  distinctly  seen  in 
a  skiagraph.  Such  an  enlargement  of  the  bone  seldom  occurs  in  the 
epiphyseal  form  of  tuberculosis,  but  if  such  is  the  case,  it  takes  place  at 
the  lower  end  of  the  radius  and  upper  ends  of  the  tibia  and  ulna. 


Fig.  399. — X-RAY  OF  a  Case  of  Tuberculous  Dactylitis,  of  Left  Metacarpal  Bone  of  Ring-finger, 
OF  Second  Phalanx  of  Right  Middle  Finger,  and  First  Phalanx  of  Right  Ring-finger. 


In  addition  to  the  enlargement  of  the  bone,  perforation  of  the  over- 
lying periosteum  occurs  at  an  early  period  with  the  formation  of  a  sinus 
discharging  thin  yellow  pus  and  hned  by  pale,  flabby,  often  caseous,  gran- 
ulations. Such  abscesses  and  sinus  formations  occur  at  an  early  stage 
in  the  case  of  tuberculosis  of  the  metacarpals  and  metatarsals,  but  at  a 
late  stage  in  the  phalanges,  which  latter  may  remain  enlarged  for  a  long 
time.     Syphilis  causes  a  similar  enlargement  of  the  short  pipe  bones, 


DISEASES    OF   THE    BONES.  585 

but  can  be  differentiated  by  the  fact  that  it  occurs  chiefly  in  infancy, 
and  there  is  no  abscess  formation.  The  history  and  a  search  for  other 
evidences  of  syphihs  will  usually  clear  up  any  doubts.  Should  the  latter, 
however,  exist,  the  administration  of  antisyphilitic  remedies  should  be 
instituted. 

3.  Tuberculosis  of  the  spongy  bones  of  the  tarsus  is  more  frequent 
than  is  that  of  the  carpus.  In  lesions  of  these  bones  the  articular 
symptoms  predominate  and  will  be  referred  to  in  the  diagnosis  of 
joint  disease. 

4.  Tuberculosis  of  the  flat  bones  of  the  extremities,  e.  g.,  of  the 
pelvis,  may  occur  either  along  the  crest  of  the  ilium,  the  symphysis 
pubis,  or  in  the  acetabulum.  The  latter  localization  may  be  the  start- 
ing-point of  a  hip-joint  disease. 

In  the  crest  of  the  ilium  and  symphysis  pubis,  tuberculosis  is  very 
rare,  and  difficult  to  recognize  until  an  abscess  or  a  sinus  which  leads 
down  to  carious  bone  has  formed. 

•    Tuberculous  periostitis  as  a  primary  affection  occurs  only  in  the 
ribs  and  has  been  described  on  page  203. 

Syphilis  of  Bone. — Syphihs  affects  the  bones  both  in  the  heredi- 
tary and  acquired  stages.  The  localization  and  pathologic  changes 
are  similar  in  both  and  will  be  described  together.  In  hereditary 
syphilis  there  is,  however,  a  greater  tendency  to  secondary  joint  involve- 
ment, the  chnical  signs  of  which  will  be  referred  to  in  the  section  on 
joint  diseases. 

The  following  are  the  most  frecjuent  locahzations  of  syphilis: 

1.  As  a  periostitis: 

(a)  In  the  early  portion  of  the  secondary  stage. 

(b)  In  the  late  secondary  stage. 

(c)  In  the  tertiary  form. 

(d)  In  late  hereditary  syphihs. 

2.  As  a  gummatous  osteomyelitis: 

(a)  In  the  tertiary  stage. 

(b)  In  the  hereditary  form. 

In  hereditary  syphihs,  bone  sxinploms  ai)i)(,';ir  (a)  as  an  osleomye- 
litis  of  the  epiphyses  of  the  long  ])ipc  bones,  causing  ])ain,  marked  en- 
largement of  the  end  of  the  bone,  a  swolUn  joint,  and  loss  of  fnnrlion 
of  the  limb  {syphilitic  pseudo- paralysis). 

(b)  As  an  osteomyelitis  of  the  short  ])i|)e  bones  (syphilitic  dactyl- 
itis), which  can  be  differentiated  froni  a  tuberculous  condition  jjy  the 
absence  of  a  tuberculous  history  and  of  a  tendency  to  abscess  forma- 
tion and  the  rapid  improvement  under  antisyphilitic  treatment. 


q86 


THE    EXTREMITIES. 


(c)  As  an  osteomyelitis  anywhere  in  the  body  with  resultant  necro- 
sis and  sinus  formation. 

(d)  As  an  osteoperiostitis  in  that  form  of  hereditary  syphihs  Avhich 
appears  about  the  age  of  puberty.  The  diagnosis  of  the  latter  two 
forms   does   not   differ  from   similar   conditions   observed  in  the  late 


A 


Fig.  400. — Method  of  Palpatixg  the  Periosteum  of  the  Tibia. 

The  fingers  are  laid  flat  upon  the  limb,  the  tips  resting  upon  the  internal  surface  of  the  tibia  or  shin,  and  the 
hand  then  passed  along  the  entire  length  of  the  tibia. 


secondary    or   in    the    tertiary    stages    of    acquired    sypliilis    (see  be- 
low). 

Acquired  Syphilis. — In  the  early  weeks  of  the  secondary  stage 
one  of  the  most  marked  symptoms,  which  appears  just  before  the  cuta- 
neous eruption  occurs,  is  the  acute  periostitis  of  the  cranial  bones  (see 
page  70).     In  the  late  secondary  or  early  tertiary  periods  tliis  local- 


DISEASES    OF   THE    BONES, 


587 


ization  is  so  characteristic  that  the  diagnosis  is  usually  not  difficult. 
The  disease  most  often  involves  the  tibia,  but  may  first  show  itself 
in  the  clavicle.  The  signs  are  (a)  severe  pain  over  the  affected 
bone  which  is  most  marked  at  night,  except  in  those  who  sleep 
during  the  day  on  account  of  their  occupation,  in  which  case  they  are 
most  severe  during  the  latter  period,  (b)  Palpation  of  the  bone  reveals 
a  distinct  thickening  of  the  periosteum  and  exquisite  sensitiveness 
to  the  touch.  This  inflammatory  form  of  syphihtic  bone  locahzation 
may  be  quite  circumscribed  (periosteal  nodes)  or  diffuse.  Even  after 
the  disease  has  sub- 
sided the  affected 
bone  may  show  upon 
palpation,  alternat- 
ing elevations  and 
depressions,  which 
may  be  of  some  aid 
in  making  a  diag- 
nosis of  syphilis  at 
some  future  period. 
These  elevations  are 
the  result  of  ossifica- 
tion of  the  periosteal 
nodes. 

G  ummat  ous 
Periostitis  and 
Osteomyel  i  ti  s. 
— These  occur  in  the 
tertiary  stage  in  one 
of  two  forms :  (a)  As 
a  superficial  perios- 
teal gumma;  (6)  as  a. 

circumscribed  or  diffuse  gummatous  in  fill  ration  of  llK'mc(hilla  of  llie  sluift. 
The  periosteal  gumma,  which  varies  from  the  size  of  a  walnut  to 
that  of  an  apple,  appears  as  a  painful,  superficial  tumor,  which  may 
become  soft  and  show  evidences  of  fluctuation,  or  graduall\-  disappear 
under  treatment.  At  times  they  may  break  down  and  perforate  the  skin, 
or  ulceration  takes  place  with  the  formation  of  typical  rcnifomi,  stccp- 
edged  ulcers. 

A  gummatous  osteomyelitis  causes  a  dull  aching  i)ain  in  the  bone 
without  palpable  changes  in  the  periosteum.  Tluiv  may  be  an  accom- 
panying marked  enlargement  of  the  shaft  of  the  bone  or  extensive 


Fig.  401. — Periostitis  Syphilitica  in  a  Boy  of  Sixteen,  Suffering 

FROM  Syphilis  Hereditaria  Tarda. 

This  is  the  same  case  as  shown  in  the  .r-ray  of  Fig.  402.     The  arrow 

points  to  the  prominence  along  the  entire  internal  aspect  of  the  tibia. 


588 


THE   EXTREMITIES. 


necrosis  may  occur.     In  some  cases,  a  spontaneous  fracture  may  be 
the  first  sign  of  the  presence  of  the  disease. 


Fig.  402. — X-RAY  OF  Case  of  Syphilitic  Periostitis  of  Tibia,  Exterior  Picture  of  Which  is  shown 

IN  Fig.  400. 


The  diagnosis  of  the  various  forms  of  bone  sypliihs  is  usually  not 
difficult,  if  there  is  a  distinct  history  or  there  are  evidences  of  the  dis- 


DISEASES    OF   THE    BONES.  589 

ease  elsewhere.  In  no  other  bone  affection  are  the  thickening,  pain, 
and  tenderness  of  the  periosteum  so  marked.  The  nocturnal  exacer- 
bation of  pain  is  also  characteristic. 

Tuberculous  periostitis,  as  was  stated,  is  very  rare  as  a  primary 
affection,  and  if  present  usually  shows  early  signs  of  suppuration. 

If  the  periosteum  has  increased  in  thickness  rapidly,  and  the  en- 
largement is  quite  marked  and  not  very  painful,  the  question  of  the 
possibility  of  a  periosteal  sarcoma  arises.  This  is  especially  true  if 
there  is  but  little  response  to  antisyphilitic  treatment,  and  the  history 
of  a  previous  syphihs  is  not  clear.  In  such  cases  an  exploratory 
incision  is  often  necessary. 

The  gummatous  form  of  osteomyelitis,  if  it  be  accompanied  by 
considerable  osteosclerosis  and  enlargement  of  the  bone,  must  at 
times  be  differentiated  from  an  osteosarcoma,  especially  if  situated 
at  the  epiphyseal  ends  of  the  long  bones.  A  gumma  in  such  a  situa- 
tion causes  a  unilateral,  while  a  sarcoma  causes  a  uniform,  enlarge- 
ment. 

A  gumma  of  the  short  pipe  bones  of  the  hand  and  foot  (metacarpals, 
metatarsals,  and  phalanges)  can  be  differentiated  from  a  tuberculous 
osteomyehtis  (spina  ventosa)  only  by  the  greater  tendency  of  the  latter 
to  suppurate  and  the  fact  that  antisyphilitic  treatment  causes  no  improve- 
ment.    The  x-ray  appearance  of  both  processes  would  be  similar  (Fig. 

399)- 

Osteomalacia, 

This  is  a  disease  of  bone  in  which  absorption  of  lime  sahs  occurs 
in  healthy  bone. 

Bending  of  the  softened  bone  leads  to  marked  deformity,  and  the 
occurrence  of  spontaneous  fracture  is  common.  The  majority  of 
cases  reported  have  been  in  women  (91  per  cent.),  and  of  these 
it   occurred  during  pregnancy   in    70  per  cent. 

There  is,  however,  a  non-puerperal  form,  which  is  of  constantly 
increasing  interest  to  surgeons,  since  the  spontaneous  fractures  occur- 
ring as  the  result  of  it  may  be  easily  diagnosed  as  being  due  to  bone 
neoplasms.  The  most  characteristic  symptoms  of  the  ])ucrperal  and 
non-|)ucrpcral  forms  arc: 

1.  Rheumatoid  pains  in  tlic  si)inr  and  the  cxlrfmilies  without 
swelling,  Init  accompanied   1)_\-  marked  nui^cular  weakness. 

2.  In  the  non-puerperal  form  there  is  a  history  of  mahuitrition  and 
of  unhygienic  surroundings. 

3.  Deformities.     These  may  be   {a)  of  the  spine— there  is  a  grad- 


59©  THE    EXTREMITIES. 

ually  increasing  curvature  of  the  spine,  which  may  be  in  a  backward, 
forward,  or  lateral  direction;  (b)  of  the  pelvis — the  walk  becomes 
waddling,  like  that  of  double  congenital  hip  dislocation,  the  pelvic 
bones  becoming  misshapen ;  (c)  of  the  chest — this  assumes  a  barrel  shape 
or  the  ribs  sink  in;  (d)  of  the  extremities — there  is  marked  bending  of 
the  long  bones. 

4.  Spontaneous  fractures.  These  occur  at  an  early  period.  They 
may  be  single  or  multiple,  and  the  possibility  of  an  osteomalacia  must 
always  be  borne  in  mind  in  cases  of  apparently  spontaneous  fracture. 

5.  Owing  to  the  absorption  of  the  calcium  salts,  the  x-ray  will  show 
a  lighter  shadow  than  normal  bone  does. 

Differential  Diagnosis. — The  bone  diseases  from  which  osteo- 
malacia must  be  differentiated  are: 

{a)  Osteosarcoma,  especially  of  the  soft  medullary  type.  This 
may,  like  osteomalacia,  cause  a  spontaneous  fracture  as  its  first  symp- 
tom. Usually,  however,  there  is  a  history  of  deep-seated  pain  located 
in  the  shaft  of  one  of  the  long  bones,  not  diffuse,  like  that  of  osteo- 
malacia, i.  e.,  felt  in  various  parts  of  the  body. 

(b)  Osteitis  Deformans. — This  occurs  chiefly  in  elderly  people, 
but  may  begin  before  forty.  The  accompanying  rheumatic  pains  and 
the  increasing  curvature  of  the  spine  and  lower  extremities  resemble 
those  of  osteomalacia,  but  there  gradually  develops  an  irregular  nodular 
thickening  of  the  various  bones.  In  addition  the  :r-ray  will  show  that 
the  normal  deep  bone  shadow  is  not  absent  as  in  osteomalacia. 

{c)  Rickets. — This  causes  bending  of  the  bones,  but  never  marked  as 
in  osteomalacia,  spontaneous  fracture  is  infrequent,  and  rachitis  occurs 
at  a  much  earlier  age  than  osteomalacia. 

Rachitis  (Rickets). 

The  diagnosis  of  this  form  of  bone  disease  usually  presents  no  dif- 
ficulties.    The  most  characteristic  symptoms  are: 

I.  Deformities. — These  are  most  marked  in  the  head,  spine, 
thorax,  and  extremities. 

{a)  Head. — The  head  is  larger  than  normal  and  of  a  square  or  box- 
shape,  owing  to  the  formation  of  bosses  over  the  parietal  and  fron- 
tal eminences.  The  sutures  and  fontanelles  remain  open  longer 
than  normal.  The  occipital  bone  often  shows  abnormal  soft- 
ness or  parchment-like  cracking  (craniotabes)  on  pressure.  This 
rachitic  condition  is  frequently  accompanied  by  a  variable  degree 
of  hydrocephalus. 

(6)  Chest. — Nodules  are  to  be  felt  at  the  junction  of  the  costal  car- 


DISEASES    OF   THE    BONES.  591 

tilages  and  ribs,  which  togctlier  form  a  series  of  bead-Hke  enlargements 
to  which  the  term  rachitic  rosary  has  been  given.  In  addition  to  this 
beading,  the  chest  is  flattened  from  side  to  side  and  the  sternum  often 
very  prominent  (pigeon-breast). 

(c)  Spine. — The  most  characteristic  deformity  is  a  backward  curv- 
ature (kyphosis),  which  is  uniformly  distributed  over  the  entire  spine. 

{d)  Extremities. — The  deformities  are  more  marked  in  the  lower  than 
in  the  upper  extremity.  The  palpable  epiphyses  of  the  various  bones  are 
markedly  enlarged.  This  is  especially  pronounced  at  the  lower  ends  of 
the  radius  and  ulna.  The  femur  is  bent  forward  and  outward  and  there 
is  frequently  an  accompanying  coxa  vara  (see  page  648).  The  other 
principal  deformities  are  genu  valgum  and  varum  (see  page  653). 
Spontaneous  and  greenstick  fractures  are  not  infrequently  due  to 
ricket^s.  The  diagnosis  can  usually  be  made  from  {a)  the  box-shaped 
skull;  (6)  beading  of  the  ribs;  (c)  enlargement  of  the  epiphyses  at  the 
wrist  when  accompanied  by  great  restlessness;  {d)  nervous  s}nTip- 
toms,  such  as  convulsions,  lar}Tigismus  stridulus;  {e)  marked  muscular 
weakness;  (/)  delayed  dentition  and  delayed  closure  of  the  fontanelles. 
There  is  never  any  breaking  down  of  bone  in  rickets,  or  formation  of 
sinuses.  A  diagnosis  of  rickets  should  never  be  made  from  a  single' 
symptom,  since  enlargement  of  the  epiphyses  may  be  due  to  heredi- 
tary syphihs.  Again,  deformities  of  the  extremities,  hke  coxa  vara 
or  genu  valgum  or  varum,  may  be  due  to  static  or  other  causes.  A 
curvature  of  the  spine  may  be  due  to  tuberculosis.  The  differentia- 
tion from  scurvy  is  given  below. 

Chondrodystrophia  Foetalis  (Achondroplasia -Fetal  Rickets). 

This  bone  affection  is  essentially  a  disturbance  of  the  normal  pro- 
cess of  Ossification  of  the  primar)-  cartilage.  The  children  are  dwarf- 
Hke  when  bom.  The  head  is  large,  the  ribs  are  beaded,  the  thorax 
flattened,  and  the  long  bones  are  bowed  and  shortened.  The  bones 
remain  distorted  and  their  growth  is  greatly  retarded. 

Scorbutus  (Scurvy,  Barlows  Disease). 
This,  Hke  rickets,  is  a  disease  of  childhood,  although  it  may  rarely 
occur  in  early  youth  or  even  in  adult  life  as  the  result  of  errors  of  diet. 
About  four-fifths  of  the  cases  occur  between  the  sixth  and  fifteenth 
months  (Holt).  Most  of  the  children  lia\c  been  in  good  health  up  to 
the  time  of  the  attack.  The  principal  surgical  interest  in  the  disease 
is  its  tendency  to  involve  the  bones.  A  surgeon  is  often  consulted  on 
account  of  the  fact  that  the  children  cry  out  with  pain  when  lifted. 


592  THE    EXTREMITIES. 

In  the  majority  of  cases  this  pain  and  tenderness  are  most  marked  in 
the  lower  extremities,  especially  about  the  knees  and  ankles. 

This  symptom  alone  should  always  lead  one  to  suspect  scurvy, 
since  acute  rheumatism  is  very  rare  in  such  young  children.  The 
accompanying  symptoms — (a)  swelling  near  or  of  the  large  joints; 
(b)  spong}^,  swollen,  often  bleeding,  gums ;  (c)  tendency  to  subcutaneous 
hemorrhages  and  to  melena,  as  well  as  (d)  the  histor}'  of  improper  diet 
(prolonged  use  of  some  proprietan,'  food  or  steriHzed  or  condensed 
milk) — will  usually  enable  a  diagnosis  to  be  made.  In  anterior  poho- 
myelitis  there  is  no  tenderness.  In  actue  osteomyelitis  there  is  fever, 
leukocytosis,  as  well  as  local  redness  and  heat.  The  swelling  of  the 
limb  mav  resemble  a  sarcoma,  but  an  .v-ray  will  soon  exclude  a  neo- 
plasm, because  the  normal  outlines  of  the  bone  are  presented  in  scurvy. 

Osteitis  Deformans  (Paget'S  Disease  of  Bone). 

This  is  an  affection  which  causes  a  softening  and  bending  of  some 
of  the  long  pipe  bones  and  of  the  spine,  due  to  absorption  of  lime  salts 
with  secondar}'  formation  of  fibrous  tissue  in  its  stead.  It  usually 
affects  the  tibia  in  elderly  persons  and  soon  involves  the  neighboring 
joints. 

The  disease  attacks  men  more  frequently  than  women.  The 
average  age  of  onset  in  twenty-one  cases,  according  to  Osgood  and 
Locke,  of  Boston,  was  forty-three  years.  The  skull  is  greatly  enlarged, 
and  there  is  neuralgia  from  pressure.  The  affection  is  often  ushered 
in  by  a  long  period  of  rheumatic  pains  and  headaches.  The  patient 
stands  with  legs  bowed  and  spine  bent  gradually  backward,  the  body  is 
carried  forward  and  bent  at  the  hips.  The  occurrence  of  bow-legs  late 
in  life  accompanied  by  enlarged  skull  and  bending  backward  of  the 
spine  are  the  chief  diagnostic  features. 

Osteoarthropathie  Pneumatique. 
This  is  a  disease  of  bone  which  was  first  described  by  Marie.     It 
occurs  in  persons  suffering  from  chronic  cardiac  and  pulmonar}"  dis- 
eases, and  consists  of  an  enlargement  (Fig.  403)  of  the  end  phalanges 
of  the  fingers  and  toes,  resulting  from  a  chronic  periostitis. 

Acromegaly. 
This  gives  such  a  characteristic  clinical  picture  that  it  seldom  causes 
any  difficulty  in  diagnosis.  There  is  marked  enlargement  of  the  bones 
of  the  face  (especially  of  the  lower  jaw)  and  of  the  hands  and  feet. 
It  is  often  a  symptom  of  tumors  of  the  pituitary  body,  as  was  the  case 
in  the  patient  whose  brain  is  shown  in  Fig.  37. 


diseases  of  the  boxes.  593 

Tumors  of  Bone. 

The  clinical  history  of  a  patient  with  a  tumor  of  one  of  the  bones 
of  the  extremities  is  usually  as  follows:  (a)  He  may  present  him- 
self, for  the  first  time,  on  account  of  a  fracture  which  followed  a 
very  sHght  trauma;  (b)  he  may  complain  of  pain  and  tenderness 
over  the  affected  bone  for  months  to  years  before  a  palpable  enlarge- 
ment appears;  or,  lastly,  (c)  a  patient  who  has  a  distinct  tumor  presents 
himself  for  examination  and  opinion. 

In  making  a  diagnosis,  one  must  consider  whether  the  enlarge- 
ment to  be  felt  is  in  reality  a  neoplasm  of  the  bone  or  whether  it  is  the 
result  of  some  inflammator}'  process,  and  if  one  has  excluded  the  latter, 


Fig.  403. OSTEOARTHROPATHIE  PnEUMATIQUE  OF  MaRIE   OF  THE  JOINTS  OF  THE  FlNCERS  OF  BOTH  HaN'DS. 

(See  text.) 

the  next  problem  is  to  determine  the  nature  of  the  tumor,  as  to  whether 
it  be  benign  or  mahgnant,  etc.  - 

If  the  patient  is  examined  for  the  first  time  on  account  of  an  appar- 
ently spontaneous  fracture,  the  various  forms  of  pathologic  fracture 
enumerated  on  page  441  must  be  excluded  one  by  one. 

If  the  spontaneous  fracture  is  due  to  the  rarefaction  of  the  osseous 
tissue  as  the  result  of  a  neoplasm  there  will  be  the  previous  histoiy,  and 
the  local  findings  to  be  enumerated  below,  as  more  or  less  characteristic 
of  the  different  forms  of  bone  neoplasms. 

It  is  impossible  to  make  a  diagnosis  of  a  bone  neoplasm  without 
38 


594 


THE   EXTREMITIES. 


referring  briefly  to  the  chief  varieties  and  then  to  consider  their  differ- 
entiation from  other  conditions: 


Benign. 
Neoplasms  of  bones  j 

of  the  extremities.  ] 

'^  Mahgnant. 


{True  or  simple  bone  cysts. 
Osteomata  and  exostoses. 
Enchondromata. 
f  Primary  and  secondary  sarcomata. 
\  Secondary  carcinomata. 


A  group  of   tumors  called  peritheliomata  is  also  found  in  bones 
which  belong  clinically  to  neither  group,  although  they  resemble  the 

sarcomata  histological- 
ly. These  perithelio- 
mata show  no  tendency 
to  produce  metastases, 
but  are  apt  to  recur 
locally  after  operation. 
Benign  Tumors. — 
True  or  Simple  Bone 
Cysts. — As  is  the  case 
with  all  bone  tumors, 
patients  may  present 
themselves,  for  the  first 
time,  with  a  spontan- 
eous fracture  due  to  this 
form  of  tumor.  If  such 
be  not  the  case,  there  is 
a  history  of  pain  over 
the  epiphyseal  ends  of 
one  of  the  long  pipe 
bones  (humerus,  femur, 
and  tibia),  which  has 
continued  during 
months  to  years,  followed  by  the  gradual  enlargement  of  the  bone 
in  the  majority  of  cases.  The  bulging  itself  is  seldom  uniformly 
firm,  but  palpation  reveals  many  soft  compressible  places.  An 
x-ray  will  show,  according  to  one  writer  (Carl  Beck  ^),  a  charac- 
teristic light  area,  surrounded  by  the  clear,  narrow  shadow  of  the  ex- 
panded cortex.  Others  (Koch  ^  and  Helbing)  do  not  believe  much 
reliance  can  be  placed  upon  the  skiagraph  in  making  a  diagnosis. 

^  "Annals  of  Surgery,"  1901,  vol.  xxxiv. 

^  "  Archiv  fur  klinische  Chirurgie,"  Bd.  Ixviii,  1902. 


Fig.  404. — Endothelioma  of  Shoulder,  Anterior  View  (Dr. 
John  A.  Hartwell). 


DISEASES    OF   THE    BONES. 


595 


The  chief  conditions  from  which  it  must  be  differentiated  are  a  chronic 
bone  abscess  resulting  from  a  former  osteomyehtis,  syphihs,  tubercu- 
losis, and  osteosarcoma.  In  the  last  named  (a)  the  growth  is  also  ven^ 
slow  and  gradual;  (b)  the  surface  is  uniformly  hard  and  does  not  show 
softer  areas  as  in  a  simple  bone  cyst.  In  many  cases  only  an  explora- 
tory incision  will  clear  up  the  diagnosis.  A  cyst  is  filled  with  a  thin 
yellowish  serous  fluid,  while  an  osteosarcoma  is  solid  throughout. 

Chronic  abscesses  due  to  an  old  osteomyelitis  are  usually  situated 
in  the  upper  end  of  the 
tibia.  They  pursue  a  very 
protracted  course  and  the 
pains  occur  periodically, 
especially  after  exertion. 
There  is  often  some  even- 
ing rise  of  temperature. 
Tuberculosis  of  bone  sel- 
dom causes  expansion  of 
a  long  pipe  bone,  but  it 
leads  to  abscesses  and  sin- 
uses at  an  early  date. 

Central  syphilitic  gum- 
mata  might  give  rise  to 
deep-seated  bone  pain. 
They  cause  no  enlarge- 
ment of  the  bone,  give  a 
negative  x-ray  picture,  and 
improve  rapidly  under  an- 
tisyphihtic  treatment.  Up 
to  the  present  time  only 
twenty-two  cases  of  simple 
bone  cysts  have  been  .  re- 
ported. 

Osteomata  and  Exosto- 
ses.— These  terms  are  fre(|ucnlly  used  to  re])rcscnt  llu'  same  tumor  ])ro- 
jecting  from  bone.  The  exostoses  are  congenital  mulliple  tumors  which 
are  most  frequently  situated  near  the  epiphyses  and  become  ossified  dur- 
ing puberty,  at  which  time  they  are  hkely  to  cause  symptoms.  They 
are  situated  where  the  long  bones  grow  most  rapidly,  viz.,  the  lower  end 
of  the  femur,  u])])er  ends  of  tibia  and  humerus.  They  grow  very  slowly, 
and  are  not  accompanied  by  pain  or  tenderness.  In  some  indi^•iduals 
these  exostoses  occur  in  multiple  form,  i.  e.,  at  every  epiphysis. 


Fig.   405. — External  View   of  Dissected   Specimen   of  an 

Osteosarcoma  of  the  Upper  End  of  Humerus. 
This  is  from  the  same  case  as  is  shown  in  Figs.  406  and  407. 


596 


THE   EXTREMITIES. 


Exostoses  may  develop  slowly,  or  in  some  cases  rapidly,  after  trauma. 
If  the  growth  has  been  rapid,  a  differentiation  from  an  ossifying  peri- 
osteal sarcoma  is  difficult.  It  can  often  only  be  made  by  an  x-ray 
examination  and  an  exploratory  incision.  In  a  periosteal  sarcoma  which 
is  becoming  an  osteosarcoma,  the  bone  shadow  is  seen  arranged  in 
spicules  hke  rays,  perpendicular  to  the  shaft  of  the  bone,  while  an 
osteoma  or  exostosis  shows  the  architecture  of  normal  bone,  i.  e.,  cor- 
tex and  medulla.  An  exostosis  following  trauma  can  also  be  distin- 
guished from  a  perios- 
teal osteosarcoma  by  the 
fact  that  its  growth 
ceases  after  a  time,  while 
that  of  the  mahgnant 
tumor  is  steady  and  pro- 
gressive. 

The  exostoses  which 
occur  in  chronic  joint  af- 
fections, like  arthritis  de- 
formans, tabetic  and 
syringomyelic  joints,  are 
readily  diagnosed  by  the 
symptoms  of  the  accom- 
panying conditions. 

Enchondr  omata . 
— ^These  occur  as  nodu- 
lated elastic  tumors, 
which  have  the  consis- 
tency of  cartilage.  Quite 
rarely,  they  are  soft,  as 
the  result  of  a  myxoma- 
tous degeneration.  They 
may  occur  as  pure  chondromata  or  as  mixed  tumors,  e.  g.,  myxochon- 
drosarcomata  or  osteochondrosarcomata.  The  two  latter  will  be  re- 
ferred to  under  Sarcomata  of  Bone. 

Pure  enchondromata  occur  most  frequently  in  the  following  bones,— 
scapula,  pelvis,  long  and  short  pipe  bones  of  the  extremities,  and  pha- 
langes of  the  fingers  and  toes.  In  the  two  latter  situations  they  occur 
more  frequently  than  in  any  other  portion  of  the  body.  In  the  meta- 
carpal bones  they  occur  as  central  tumors,  which  gradually  cause  an 
expansion  of  the  bone  like  a  spina  vcntosa.  On  the  lingers  and  toes 
enchondromata  occur  as  multiple  tumors  and  pursue  a  very  benign 


Fig.  406. — View  of  Longitudinal  Section  of  an  Osteosarcoma 

OF  THE  Upper  End  of  the  Humerus. 

NB,  Ossifying  periosteal  layer;  5,  softer  portion  of  tumor. 


DISEASES    OF   THE    BONES.  597 

course,  but  in  other  bones  may  grow  to  enormous  size.  The  diagnosis 
of  enchondromata  of  bone  is  not  difficult  on  account  of  their  (a)  slow- 
growth;  {h)  consistency;  (c)  location  as  single  or  multiple  tumors  at 
the  epiphysis;  {d)  the  .x-ray  shows  a  light  shadow;  {e)  absence  of 
pain  and  tenderness. 

Sarcoma   of  Bone. — This    is  the   most  frequent  form    of    bone 


Fig.  407. — X-RAY  OF  THE  Osteosarcoma  of  Upper  End  of  Humerus,  shown  in  Fig.  406. 

tumor.  As  secondary  growths  sarcomala  of  bone  arc  a  frr(|urnl  re- 
sult of  metastasis  of  a  ]jrimar_\-  sarcoma  of  the  brcasl,  testis,  etc. 
They  differ  from  the  secondary  carcinomata  of  bone  in  tin'  clinical 
fact  that  the  primary  growths,  in  tlic  latter  case,  are  often  insignifi- 
cant when  bone  metastases  occur,  while  in  the  case  of  sarcoma  the 
bone  metastases  appear  at  an  earlier  period  and  the  diagnosis  of  the 
primary  growth  has  usually  been  made,     ^^any  cases  of  malignant  bone 


598  THE    EXTREMITIES. 

neoplasms  may  first  present  themselves  for  diagnosis  on  account  of 
a  fracture,  which  has  either  occurred  spontaneously  or  after  slight 
violence.  Other  cases  may  present  themselves  with  the  history  of  a 
tumor  of  the  testis  or  other  organs  having  been  operated  upon  one  to 
two  years  previously,  followed  by  pain  over  the  hip,  limping,  and 
shortening  of  the  lower  limb,  as  shown  in  Fig.  408.  An  .r-ray  in  such 
cases  shows  a  clear  space  opposite  the  head  of  the  femur,  due  to  bone 
absorption  by  the  metastatic  growth. 

The  diagnosis   of   secondary   sarcomata  differs  from  that  of   the 
primary  forms  only  through  the  absence  in  the  latter  of  a  primary 


J"' 


Fig.  408. — Sarcoma  of  Knee-joint. 
Observe  the  flexion  contracture,  and  the  enormous  enlargement  of  the  lower  end  of  the  femur,  in  which  the 

tumor  was  primary. 

seat,  and  the  fact  that  the  secondary  forms  show  a  more  rapid  growth 
and  less  of  a  tendency  to  ossification. 

Primary  Forms  of  Sarcomata  of  Bone. — In  the  diagnosis  of 
these  an  effort  should  be  made  to  include,  if  possible,  the  exact  variety 
of  sarcoma,  since,  from  a  clinical  point  of  view,  they  differ  greatly  in 
their  malignancy. 

They  generally  occur  in  two  forms:  One,  the  periosteal,  and  the 
other  the  myelogenous.  Both  forms  have  as  seats  of  predilection  the 
epiphyseal  ends  of  the  long  pipe  bones.  The  following  table  shows  the 
percentage : 

Upper  epiphysis  of  tibia, 35  per  cent. 

Lower  end  of  femur, 18         " 

Upper  end  of  humerus, 13         " 

Ulna  and  radius, 4         " 


DISEASES    OF   THE    BONES.  599 

The  periosteal  sarcomata  are  usually  of  the  small  round  and  spindle- 
celled  type.  They  give  rise  to  enormous  tumors,  which  may  at 
times  undergo  ossification,  the  lime  salts  being  deposited  in  a  needle- 
like manner  radiating  from  the  shaft.  Giant-celled  sarcomata  of  the 
periosteum  are  quite  rare. 

Myelogenous  sarcomata  may  be  of  the  round,  spindle-,  or  giant- 
celled  type.  These  tumors  cause  rapid  expansion  of  the  medulla,  but 
at  the  same  time  new  bone  is  formed  from  the  overlying  periosteum 
(see  Fig.  405).  This  form  is  often  associated  as  an  osteochondrosar- 
coma or  as  a  myxochondrosarcoma. 


\ 


Fig.  409. — Upward  Dislocation  of  Xkck  and  Shaft  of  Femur,  Following  Absorption  of  Head  the 
Result  of  a  Metastatic  Sarcoma,  Primary  Growth  in  Testes  (X-ray  Copy). 

In  general,  it  may.  be  said  that  the  softer  a  Ijonc  sarcoma  is,  the 
more  rapid  is  its  growlli  and  tlie  greater  its  malignancy. 

The  diagnosis  of  bone  sarcomata  may  l:>c  made  from  the  following 
data: 

1.  They  occur  at  the  epi|)hyseal  ends  of  the  most  rapidly  growing 
bones  (femur,  tibia,  and  lumurus)  of  young  adults.  Only  5  per  cent, 
occur  beyond  the  age  of  forty. 

2.  In  the  periosteal  form  a  palpable  enlargement  of  the  bone  appears 
quite  early,  and  is  soft  unless  ossification  lias  occurred. 

3.  In  the  medullary  form  the  patient  complains  for  some  time  of 
pain  over  the  end  of  one  of  the  above-mentioned  long  bones.     After 


6oo 


THE   EXTREMITIES. 


Cancellous 
tissue  with 
red  mar- 
row 


a  variable  period  a  swelling  appears  at  the  seat  of  pain,  and  may  be 
hard  or  soft,  according  to  the  amount  of  osseous  tissue. 

4.  Trauma  in  young  adults,  followed  by  pain  and  tenderness 
which  do  not  disappear  within  a  month,  should  be  watched  as  indi- 
cating the  possibility  of  development  of  sarcoma. 

5.  A  rise  of  temperature,  and  effusion  into  the  adjacent  joint  is  not 
uncommon,  especially  in  the  periosteal  form. 

6.  The  growth  of  bone  sarcomata  varies  greatly.     In  the  giant- 

celled  and  in  the  osteosarcomata  it  is  very 
slow.  In  the  other  varieties  it  is  more  rapid 
and  progressive  than  that  of  any  other 
form  of  bone  neoplasm. 

7.  The  x-rsLj  is  of  value  in  distin- 
guishing bone  neoplasms  from  inflamma- 
tory processes  or  trophic  changes.  It  may 
be  said  that  the  more  cellular  types, 
like  the  periosteal  and  the  small  rounded 
myelogenous  sarcoma,  generally  show  a 
translucency  or  faint  shadow  (Fig.  407) 
wherever  the  bone  has  been  involved. 
The  ossifying  periosteal  and  myeloge- 
nous sarcomata  give  the  most  typical 
pictures.  In  the  former  (periosteal  osteo- 
sarcoma) the  tine  spicules  of  bone  are 
shown  radiating  from  the  periosteum.  In 
the  central  or  myelogenous  osteosarcomata 
the  .-v-ray  shows  a  deep  shadow  with 
irregular  margins  throughout  the  extent 
of  the  growth,  thus  differing  from  the  soft 
myelogenous  forms  which  show  a  faint 
shadow. 

8.  Spontaneous  fracture  is  a  valuable 
sign  in  both  the  benign  (osseous  cysts)  and  malignant  types  of 
bone  neoplasms.  It  may  be  the  first  symptom  on  account  of  which 
the  patient  consults  the  physician. 

9.  In  some  osteosarcomata  with  large  vascular  spaces  pulsation  is 
so  marked  as  to  simulate  an  aneurysm. 

In  the  differential  diagnosis  of  osteosarcomata  one  must  consider  (a) 
tuberculosis  of  bone,  (b)  chronic  abscess  resulting  from  a  former  acute 
osteomyelitis,  (c)  simple  or  benign  osseous  cysts,  (d)  other  forms  of 
malignant  bone  neoplasms,  such  as  myelomata,  peri-  and  endothehomata, 
and  secondary  carcinomata. 


Fig.  410. — Sectional  View  of  Ossi- 
fying Periosteal  Sarcoma  of 
THE  Tibia  in  a  Girl  (J.  Bland- 
Sutton). 


DISEASES    OF   THE    JOINTS    IN   GENERAL.  6oi 

The  chief  differential  points  of  the  first  three  were  enumerated  under 
simple  bone  cysts.  The  other  forms  of  malignant  neoplasms  can  only 
be  differentiated  from  sarcoma  by  a  consideration  of  the  history  of  the 
case  and  the  age  of  the  patient.  Carcinomata  are  always  secondare'  to 
a  primar}^  growth  in  the  thyroid,  prostate,  or  breast,  and  occur  at  a  late 
period  of  life. 

Endo-  and  peritheliomata  of  bone  occur  after  forty,  as  a  rule,  but 
do  not  differ  clinically  in  other  respects  from  the  ordinary-  forms  of 
sarcomata. 

Myelomata  cannot  be  differentiated  from  sarcomata  clinically. 

Other  Forms  of  Malignant  Bone  Neoplasms. — In  considering 
the  diagnosis  of  the  nature  of  a  malignant  bone  neoplasm  one  must  not 
omit  the  following  forms: 

1.  Carcinoma. — This  usually  occurs  as  a  metastasis  of  a  primary 
carcinoma  of  the  breast,  prostate,  or  thyroid.  It  occurs  most  fre- 
quently in  the  femur,  and  the  primary  tumor  may  have  been  over- 
looked until  a  spontaneous  fracture  occurs. 

2.  Myelomata  are  composed  of  tissue  which  is  similar  to  that  of 
the  red  marrow  of  young  bone.  The  tumor  arises  in  the  medulla  of 
the  bone,  and  on  section  looks  like  a  freshly  cut  liver.  It  occurs  oftenest 
in  the  tibia.  Quite  rarely  the  tumor  is  found  in  the  lower  end  of  the 
radius  and  ulna,  upper  end  of  the  fibula  and  humerus,  and  lower  end 
of  the  femur.  The  patients  are  young  adults.  The  growth  of  the 
tumor  and  expansion  of  the  bone  take  place  very  slowly,  so  that  they 
behave  more  like  the  giant-celled  central  sarcomata. 

Endo-  and  Peritheliomata  of  Bone. — About  twenty-three  cases^  have 
been  reported  of  this  form  of  bone  tumor,  which  can  only  be  distinguished 
clinically  from  osteosarcoma  by  the  fact  that  o\-cr  seventy-three  per 
cent,  occur  after  the  age  of  forty,  while  sarcoma  is  rare  at  that  period 
of  life. 


DISEASES  OF  TKE  JOINTS  IN  GENERAL. 
When  the  surgeon  or  ])hysician  is  consuhcd  b\-  a  paticiit  suffering 
from  some  joint  affection,  the  first  question  he  asks  liimsrU"  is,  What 
is  the  nature  0 1  the  condition^  In  order  lo  \k'  able  to  systematically 
exclude  one  etiologic  factor  after  the  other,  it  is  necessary  to  have  some 
classification  of  joint  diseases  whicli  sliall  serve  as  a  working  basis. 
In  the  light  of  our  present  knowledge  tlie  most  satisfactory  division  is 
into  two  great  clinical  groups,  the  acute  and  chronic.     It  is  necessary, 

'  Howard  and  Crilc:   "Annals  of  Surgery,"  Sept.,  1905. 


6o2 


THE    EXTREMITIES. 


however,  to  state  that  there  is  often  no  hard  and  fast  Hne  between  these 
two,  since  affections  placed  under  one  head  will  often  present  them- 
selves clinically  in  such  a  form  as  to  make  it  seem  more  appropriate 
to  place  them  under  the  other.  Until  the  etiology  and  pathology  of 
chronic  articular  rheumatism  and  arthritis  deformans  is  thoroughly 
investigated,  no  large  grouping  for  these  two  affections  will  seem  ap- 
propriate. They  are  undoubtedly  of  infectious  origin,  but  the  exact 
nature  of  the  latter  is  as  yet  undetermined. 

A  classification  which  will  be  found  most  useful  from  a  diagnostic 
point  of  view  is  that  suggested  by  Konig. 

The  general  term  "arthritis"  is  used  in  preference  to  that  of  syno- 
vitis for  some  affections.  Clinically  the  distinction  cannot  always  be 
made  between  a  case  of  synovitis  and  one  of  arthritis,  since  the 
same  affection  may  at  one  time  involve  only  the  synovial  membrane 
and,  at  another,  all  of  the  structures  of  the  joint. 

The  classification  is  as  follows: 


Acute  Arthritis. 
I.  Primary  acute  arthritis. 

1.  Acute  traumatic. 

2.  Acute  articular  rheumatism. 

3.  Acute  gout  (described  under  gout). 
II.  Secondary  acute  arthritis. 

A.  Metastatic  arthritis. 

1.  Through  ordinary  pus  cocci,  pye- 

mic arthritis. 

2.  Through    other    specific    microor- 

ganisms, 
(a)  Typhoidal  arthritis. 


(&) 


Pneumococcus  arthritis. 
Influenzal  arthritis. 


{d)  Scarlatinal  arthritis, 
(e)    Gonorrheal  arthritis. 
(/)    Syphilitic    arthritis    (secon- 
dary stage). 
Secondary  acute  arthritis  by  exten- 
sion. 

1 .  From  an  osteomyelitic  focus  (acute 

arthritis  of  infants) . 

2.  From  the  surrounding  soft  tissues 

(erysipelas,  phlegmon,  bursitis, 
tendo-vaginitis  and  lymphan- 
gitis). 


Chronic  Arthritis. 
I.  Tuberculosis. 

1.  Primary  osteal. 

2.  Primary  synovial. 

II.  Chronic  serous  synovitis.     (Chronic 
articular  synovitis.) 

III.  Arthritis  deformans. 

IV.  Chronic  articular  rheumatism. 

V.  Chronic  and  atypical  gouty  arthritis. 
VI.  Syphilitic  arthritis. 
VII.  Neuropathic  arthritis. 

(a)  Tabes. 

(b)  Syringomyelia. 

VIII.  Hemophiliac  and  scorbutic  arthritis. 
IX.  Tumors  of  joints. 
X.  Hysterical  joints. 


In  attempting  to  make  a  diagnosis  of  a  joint  affection,  it  is  neces- 
sary to  keep  some  such  classification  constantly  in  mind. 


DISEASES    OF   THE    JOINTS    IN   GENERAL. 


603 


The  examination  should  embrace  the  following: 

1.  An  accurate  history  of  the  duration  and  mode  of  onset. 

2.  The  general  condition  of  the  patient. 

3.  The  examination  of  the  affected  joint  or  joints. 

I.  History  of  the  Case. — If  carefully  taken  this  will  yield  much  in- 
formation as  to  (0)  the  mode  of  onset,  whether  sudden  or  gradual; 
(h)  its  relation  to  an  injury  either  recent  or  at  some  remote  period; 
(c)  whether  the  affection  accom- 
panied some  one  of  the  systemic 
infections  just  mentioned;  {d) 
whether  it  appeared  after  symp- 
toms of  a  local  infection  had 
existed;  {e)  the  family  and  per- 
sonal history,  as  to  hereditary  or 
acquired  diseases,  habits,  hemo- 
phiha,  etc. 

2.  The  General  Condition  of 
the  Patient. — This  embraces  a 
thorough  examination  of  the 
entire  body,  including  tempera- 
ture, pulse,  condition  of  lungs, 
heart,  and  other  viscera,  and  of 
the  nervous  system.  Without 
such  a  general  survey  a  case  of 
tabetic  joint,  for  example,  may 
be  easily  overlooked.  Again,  the 
coexistence  of  tuberculous  foci 
elsewhere  will  often  throw  great 
hght  on  the  nature  of  an  obscure 
chronic  joint  affection.  Evi- 
dence of  cardiac  or  other  serous       fig.  411 -—f-xti-knai-Vikw  of  patient  with  piri- 

.  ,  .  •       r  4.  OSTEAL  Sarcoma  of  Upper  End  of  Fibula. 

membrane  mvolvement  is  of  great       ^^^^  ^^^^^^  ^^.^^^  ^^  ^^^  ^^^^^,^  ^^,^^^^^  ^^^^^  .,^^_,^^ 
value  in  the  diagnosis  of  rlieuma-  region, 

tic  affections. 

x\t  times  a  therapeutic  test  is  necessary,  in  onkT  to  dear  u])  a  diag- 
nosis of  rheumatism  or  syphilis. 

3.  Examination  of  the  Joint.— (a)  Inspection  reveals  llic  presence  or 
absence  of  swelling,  deformity,  redness,  cck^ma  of  the  ()\erlyingskin,  etc., 
in  the  more  superficial  joints. 

(b)  Palpation  shows  the  presence  or  ab.sence  of  lluctuation,  of 
locahzed  or  general  tenderness,  and  of  the  degree  of  li.xationof  the  joint. 


i 


6o4  THE    EXTREMITIES. 

(c)  Exploratory  puncture.  This  is  a  very  valuable  aid  in  ascer- 
taining the  character  of  the  fluid,  and  must  be  performed  with  every 
possible  regard  for  asepsis  (see  Fig.  412). 

(d)  X-ray.  This  gives  much  information  in  regard  to  the  con- 
dition of  the  articular  ends  of  the  bones  entering  into  the  joint  forma- 
tion. In  acute  cases  it  is  of  httle  value;  in  chronic  cases  the  changes 
are  often  slight  or  appear  very  late,  especially  in  tuberculosis. 

(e)  Mensuration.  The  measurement  of  a  joint  and  the  com- 
parison of  the  result  obtained  Avith  that  of  the  corresponding  joints 
of  the  opposite  limb  is  of  great  value  in  confirming  other  data. 

The  chief  diagnostic  features  of  the  principal  joint  affections  are 
as  follows : 

Acute  Traumatic  Arthritis. 
This  may  follow  (a)  a  blow  over  a  joint  or  a  fall  upon  a  joint;  (b) 
a  distortion  or  twisting;  (c)  it  may  accompany  a  dislocation  and,  finallv, 
(d)  it  occurs  as  the  result  of  a  fracture  into  the  joint  or  in  close  prox- 
imity to  it.  The  history'  is  usually  quite  clear.  The  injur}-  is  followed 
by  severe  pain  over  the  joint  and  by  loss  of  function.  Within  a  few 
hours  there  is  noticeable  swelhng  of  the  joint.  It  loses  its  normal  con- 
tour, all  of  the  depressions  over  it  being  eftaced  by  the  rapidly  increas- 
ing swelhng. 

Exploratory  puncture  is  rarely  necessary  for  diagnostic  purposes. 
If  performed,  however,  the  exudate  will  be  found  to  be  a  clear,  straw- 
colored  fluid  containing  much  albumin,  more  or  less  fibrin,  and  a  few 
leukocytes. 

As  a  rule,  fever  is  not  a  diagnostic  sign  in  an  acute  traumatic  ar- 
thritis. There  is,  however,  a  rare  possibility  of  a  pyogenic  infec- 
tion of  hematogenous  origin,  which  will  change  the  clinical  picture. 
Under  these  latter  circumstances  the  pain  and  swelling  will  be  exces- 
sive. The  presence  of  such  increased  local  signs,  accompanied  by 
constantly  increasing  leukocytosis  and  fever,  will  speak  for  a  joint 
infection. 

Another  fact  is  also  of  value  from  a  diagnostic  point  of  view.  A 
joint  trauma  may  be  followed  by  an  acute  gonorrheal  arthritis  in  a 
patient  sufl'ering  from  a  subacute  gonorrheal  urethritis.  Such  a  case 
is  not  readily  recognized  unless  it  be  borne  in  mind  that  infection  of 
a  traumatic  arthritis  is  very  rare.  If  fever  and  other  signs  occur  in 
such  a  joint,  a  search  should  be  made  for  primary  foci  of  pus  infec- 
tion, such  as  the  urethra,  etc. 

Acute  traumatic  arthritis  is  also  of  interest  on  account  of  its  sequelae. 


DISEASES    OF   THE    JOINTS    IN   GENERAL.  605 

It  usually  disappears  gradually,  but  may  become  chronic.  The  effu- 
sion either  remains,  or  it  disappears  and  then  recurs  from  time  to  time. 
In  the  former  case  the  disease  is  termed  a  chronic  serous  synovitis 
(see  page  614).  In  the  latter,  i.  e.,  when  it  recurs,  it  is  often  given  the 
special  name  intermittent  articular  hydrops  (see  page  614). 

Among  the  other  sequelae  of  an  acute  traumatic  arthritis  or  sprain 
of  a  joint,  may  be  mentioned  a  subluxation  of  the  articular  cartilage, 
the  formation  of  free  or  floating  bodies,^  and  finally  the  development 
of  tuberculous  foci  in  the  joint  itself  or  in  the  epiphyseal  ends  of  the  long 
bones  in  close  proximity  to  it. 

Acute  Articular  Rheumatism. 

This  form  of  joint  affection  is  usually  polyarticular,  but  it  may 
appear  in  one  joint  and  follow  a  trauma.  Under  the  latter  conditions 
the  clinical  signs  may  be  almost  identical  with  that  of  a  sprain. 

The  question  can  seldom  be  decided,  without  observing  the  rapid 
improvement  following  antirheumatic  treatment  (saHcylates,  etc.). 

Local  examination  of  a  rheumatic  joint  of  the  monarticular  type 
also  shows  greater  tenderness  over  the  affected  joint,  frequently  ac- 
companied by  some  degree  of  fever. 

If  polyarticular  the  diagnosis  is  not  difficult  in  the  more  acute 
forms.  The  joints  are  greatly  swollen,  there  being  considerable  edema 
of  the  periarticular  tissues.  There  is  also  a  variable  degree  of  fever, 
usually  from  101°  to  104°  F.  The  joint  symptoms  are  frequently 
accompanied  by  sweats  and  evidences  of  involvement  of  the  serous 
membranes,  especially  of  the  heart.  The  disease  is  also  characterized 
by  its  tendency  to  wander  from  one  joint  to  the  other. 

The  greatest  difficulty  in  both  the  monarticular  and  polyarticular 
forms  is  to  differentiate  them  from  the  other  varieties  of  multiple  joint 
infection.  The  latter  are,  as  a  rule,  secondary  to  foci  elsewhere,  whereas 
in  an  acute  rheumatism  such  primary  foci  cannot  be  found.  The 
rnost  frequent  source  of  difficulty  is  to  differentiate  multiple  gonorrheal 
joint  invasion  from  that  of  an  acute  rheumatic  form. 

Another  form  of  arthritis  which  may  simulate  the  acute  rheumatic 
form  is  that  resulting  from  an  osteomyelitic  focus  of  suppuration  in 
the  epiphyseal  ends  of  the  long  bones,  such  as  the  femur  or  tibia.  In 
the  more  superficial  joints,  like  the  knee  or  shoulder,  the  more  severe 
local  signs,  such  as  pain,  tenderness,  etc.,  will  enable  one  to  differen- 
tiate  this    form   of   acute   arthritis.      In   deeply   situated   joints,    like 

'  For  a  description  of  the  diagnosis  of  these  complications  see  Injuries  of  Joints  on  page 


6o6  THE    EXTREMITIES. 

the  hip,  the  diagnosis  is  more  difficult.  This  form  of  acute  septic 
arthritis  occurs  chiefly  in  children,  and  is  accompanied  by  far  more 
grave  symptoms  of  infection  than  is  the  case  in  an  acute  articular  rheu- 
matism. 

In  infants  such  an  acute  osteomyelitis  of  the  hip  with  secondan^ 
arthritis  causes  high  fever,  severe  pain  on  movement  of  the  limb,  flex- 
ion, and  early  abscess  formation.  In  older  children  there  is  also  high 
fever,  leukocytosis,  delirium,  much  swelling,  and  marked  local  joint 
S}Tnptoms.  The  presence  of  these  localizing  signs,  the  invasion  of 
a  single  joint,  and  the  more  severe  constitutional  symptoms  enable  a 
dift'erential  diagnosis  from  an  acute  rheumatism  to  be  made.  The 
differentiation  of  gout,  acute  arthritis  deformans,  and  acute  forms  of 
tuberculous  arthritis  will  be  considered  under  the  respective  heads. 

Secondary  Acute  Arthritis. 

As  was  stated  above,  a  primary  purulent  arthritis  is  very  rare.  Usu- 
ally such  an  acute  infectious  joint  disease  is  secondar}-  to  a  more  or 
less  distinct  primary  focus.  It  is  of  the  utmost  importance  to  recognize 
this  fact  when  called  upon  to  make  a  diagnosis  of  an  acute  arthritis. 

It  is  not  always  easy  to  state  definitely  the  exact  nature  of  the 
process. 

1.  The  histor}^  should  be  carefully  taken  to  ascertain  (a)  whether 
the  joint  affection  followed  one  of  the  acute  infectious  diseases  to  be 
mentioned  below;  (b)  whether  it  was  preceded  by  an  acute  or  a  subacute 
gonorrheal  process;  (c)  w^hether  it  foUoAved  a  pyemia,  and,  finally, 
(d)  whether  it  was  preceded  by  CAidences  of  infection  in  the  bones 
forming  the  joint  or  in  the  soft  tissues  around  it. 

2.  The  examination  of  the  exudate  should  be  regarded  as  a  more 
or  less  routine  procedure  in  the  diagnosis  of  this  class  of  joint  afl'ections. 
This  is  conducted  by  aspirating  (Fig.  412)  some  of  the  eft'usion  and 
examining  it  cytologically,  as  well  as  staining  it  for  microorganisms 
and  inoculating  culture-media  from  it. 

The  exudate  may  often  be  sterile,  or  the  organisms  can  only  be 
demonstrated  after  repeated  examinations. 

The  acute  arthritis  of  this  group  may  be  secondary  to  one  of  the 
following : 

1.  To  a  pyemia  or  septicopyemia — staphylococcus  aureus  and 
streptococcus  pyogenes  infection. 

2.  To  one  of  the  acute  infectious  diseases — typhoid,  pneumonia, 
influenza,  scarlatina,  gonorrhea.  With  the  exception  of  scarlatina,  the 
specific  organisms  of  the  respective  diseases  can  be  found. 


DISEASES    OF   THE    JOINTS    IN    GENERAL. 


607 


3.  Secondar}"  to  an  acute  osteomyelitic  focus  or  to  infection  in  the 
soft  parts.  Ordinary  pus  cocci,  unless  the  primary  disease  has  been 
caused  by  other  organisms,  are  usually  found. 

The  clinical  characteristics  common  to  the  majority  of  these  cases 
of  secondary  acute  infectious  arthritis,  are  marked  swelling,  tender- 
ness on  palpation,  pain  on  motion,  loss  of  function,  a  variable  degree 
of  fever,  leukocytosis,  and  more  or  less  constitutional  disturbances. 
The  disease  may  affect  a  single  joint  or  be  polyarticular.  The  joints 
involved  are  seldom  as  exquisitely  painful ;  there  is  also  less  tendency  to 
a  shifting  about  from  one  joint  to  another,  and  there  is  a  higher  degree  of 
leukocvtosis  than  in  acute  articular  rheumatism. 


.>A 


Fig.  412. — Method  of  Performing  Exploratory  Puncture  of  the  Knee-joint. 
The  point  of  election  is  one  situated  to  either  side  of  the  patella,  preferably  the  outer,  e.  g.,  point  indicated 
in  the  illustration  by  the  cross.     The  needle  is  inserted  beneath  the  patella,  which  has  been  raised  up  by  the 
fluid,  and  the  piston  gradually  withdrawn. 


Several  of  these  forms  of  acute  secondary  arthritis  require  special 
mention. 

Arthritis  Secondary  to  Pus  Foci  Elsewhere  (Pyemic). — This 
form  occurs  during  the  course  of  a  general  infection  with  the  ordinary 
pyogenic  organisms,  viz.,  the  staphylococcus  aureus  and  the  strep- 
tococcus pyogenes.  When  the  joint  affection  is  the  direct  result  of 
a  well-pronounced  pyemia  or  septicopyemia  it  presents  but  little  diffi- 
culty in  diagnosis.  The  cases,  however,  in  which  the  primarv  lesion 
was  a  furuncle  or  some  other  comparatively  insignificant  focus,  such 
as  a  tonsilhtis,  otitis,  etc.,  present  far  more  difficulty.  The  exudate 
is  always  purulent,  and  contains  the  organisms  which  have  caused  the 


6o8  THE    EXTREMITIES. 

priman'  disease.  Usually  the  disease  is  monarticular,  the  joint  being 
greatly  swollen  and  very  painful.  The  local  disease  is  accompanied 
by  high  fever  and  other  septic  symptoms.  The  periarticular  edema 
is  ver}'  marked,  and  perforation  of  the  capsule,  followed  by  extensive 
necrosis  of  the  joint  cartilage,  occurs  at  an  early  stage. 

Typhoidal  Arthritis. — This  is  an  infrequent  complication  of 
typhoid  fever.  The  infection  is  seldom  due  to  the  specific  bacillus 
alone.  In  the  majority  of  cases  it  is  a  mixed  infection,  i.  e.,  in  associa- 
tion w^ith  the  ordinar}'  pus  cocci  and  the  colon  bacillus.  The  joint 
complications  occur  usually  during  convalescence,  or  even  months 
or  years  after  the  attack  of  fever.  If  it  occur  during  convalescence 
the  general  symptoms  are  prolonged,  and  there  is  more  or  less  fever. 
The  local  s}Tnptoms  are  not  very  severe,  the  pain,  swelling,  and  ten- 
derness not  being  marked. 

The  exudate  may  contain  the  typhoid  bacillus  alone.  In  the  ma- 
jority of  cases  the  specific  organism  is  mixed  with  staphylococci  or 
colon  bacilli.  That  which  has  been  previously  stated  as  true  of  all  of 
the  arthritides  of  secondary  origin  is  true  of  this  form,  viz.,  that  the  joint 
exudate  may  be  found  sterile.  The  exudate  can  be  either  serous  or  pur- 
ulent, and  the. disease  may  affect  only  one  or  several  joints. 

Pneumococcus  Arthritis. — This  form  of  arthritis  may  occur  (a) 
as  a  direct  compKcation  of  a  pneumonia;  (b)  as  a  metastasis  of  a  pneu- 
mococcus septicemia,  or  (c)  as  a  purely  local  disease  ^dthout  any  pre- 
ceding pneumonia  or  any  septic  symptoms. 

When  the  arthritis  occurs  as  a  complication  of  pneumonia  it  usually 
appears  during  the  period  of  convalescence.  The  joint  symptoms  are 
quite  marked.  The  pain  varies  in  severity  from  a  slight  to  a  ver}'  severe 
one.  Tenderness  and  swelhng  of  the  joint  are  very  pronounced.  Red- 
ness and  widespread  edema  indicate  an  involvement  of  the  periarticular 
tissues,  and  in  some  cases  quoted  by  Herrick  ^  an  abscess  was  found  in 
the  structures  about  the  articulation. 

The  lesion  is  usually  monarticular,  the  knee-joint  being  most  often 
involved.  Exploratory  aspiration  of  the  joint  effusion  with  bacteriolo- 
gic  examination  of  the  fluid  is  the  only  means  of  recognizing  the  pneu- 
mococcic  character  of  the  disease.  It  must  not  be  forgotten  that  an 
arthritis  following  a  pneumonia,  may  be  due  to  the  ordinary  pus  cocci. 
The  joint  fluid  may  also  be  sterile  at  the  time  of  the  examination,  so  that 
repeated  punctures  should  be  made. 

.     The  constitutional  symptoms  show  great  variations  (Herrick).     In 
some  cases  the  joint  symptoms  are  insignificant  as  compared  with  those 

'  "American  Journal  of  Medical  Sciences,"  1902. 


DISEASES    OF   THE    JOINTS    IN    GENERAL.  609 

involving  the  pleura,  pericardium,  meninges,  or  lung.  In  other  cases 
■the  cHnical  picture  is  that  of  a  severe  septicemia,  viz.,  high  fever,  dry 
tongue,  rapid  pulse,  delirium,  etc.  In  a  third  class  of  cases,  the  arthri- 
tis is  apparently  primary  without  pulmonary  localization.  This  latter 
variety  is  the  one  which  is  often  secondary  to  a  pneumococcus  osteo- 
myehtis.     The  exudate  is  usually  purulent. 

Arthritis  Following  Other  Infectious  Diseases. — Pain,  swelhng, 
tenderness,  and  loss  of  function  of  a  joint  may  appear  during  the  course 
of  a  large  number  of  other  infectious  diseases,  e.  g.,  scarlatina,  measles, 
diphtheria,  dysentery,  influenza,  cerebrospinal  meningitis,  variola,  and 
secondary  syphilis.  The  diagnosis  of  the  nature  of  the  arthritis  can  only 
be  made  if  there  is  a  history  of  the  primary  disease.  The  arthritis  may 
be  monarticular  or  polyarticular.  The  exudate  is  usually  serous,  rarely 
sero-purulent. 

Exploratory  aspiration  is  rarely  necessary  in  order  to  make  a 
diagnosis. 

Gonorrheal  Arthritis. — This  form  of  secondary  arthritis  presents 
such  a  varied  clinical  picture  that  its  recognition  often  presents  great 
difficulty. 

Clinically  and  pathologically  there  are  four  forms :  ^ 

I.  Hydrops.  This  is  the  mildest  form.  The  arthritis  is  usually 
monarticular.  The  joint  most  often  affected  is  the  knee.  If  fever  and 
general  disturbances  are  present  they  are  shght.  There  is  but  httle  pain, 
and  the  loss  of  function  is  chiefly  due  to  the  swelhng.  The  effusion  is 
of  a  serous  character,  clear,  and  often  of  a  greenish  tint. 

2  and  3.  Serofibrinous  and  purulent  forms.  The  symptoms  are  more 
intense.  There  is  moderately  high  fever  and  tenderness,  and  the  pain  on 
movement  is  quite  severe.  The  capsule  is  greatly  thickened  and  there 
is  more  paraarticular  involvement  than  in  the  serous  form,  so  that  anky- 
losis is  not  an  infrccjuent  sequela. 

4.  The  phlegmonous  form.  This  is  the  most  virulent,  and  is  often 
polyarticular.  The  local  symptoms  are  best  seen  in  superficial  joints, 
like  the  ankle,  wrist,  or  knee. 

This  fourth,  is  the  most  characteristic  form  of  gonorrheal  arthritis 
and  occurs  in  adults  as  a  comphcation  of  a  urethritis.  In  children  it 
frequently  follows  a  vaginitis,  but  it  may  occur  in  male  babies  (Holt) 
without  other  clinical  evidence  of  gonococcus  infection. 

It  may  involve  only  a  single  joint,  but  more  frequently  is  poly- 
articular, representing  a  gonococcus  pyemia. 

The    disease    may    begin    suddenly    with    severe    pain,    swelling, 

1  I  have  followed  the  classification  of  Konig,  which  appears  the  most  satisfactory. 
39 


6lO  THE    EXTREMITIES. 

tenderness,  redness,  and  edema  of  the  affected  joint  or  joints.  The 
general  symptoms  in  such  cases  are  extreme.  There  is  but  Httle  fluid  in 
the  joint,  the  swelHng  and  pain  being  the  most  marked  local  signs. 
In  a  few  cases  intraarticular  abscesses  form  at  an  early  period. 

In  children  ^  the  general  symptoms  are  of  a  pyemic  character  with 
marked  prostration. 

After  such  an  acute  onset,  the  course  of  the  case  becomes  very  chronic, 
resulting  in  complete  destruction  of  the  joint,  i.  e.,  its  ligaments  become 
lax,  the  cartilages  are  destroyed,  and  ankylosis  follows. 

Gonorrheal  arthritis  may  run  a  subacute  or  chronic  course  from  the 
onset.  The  patients  often  complain  of  flying  pains  in  the  joints.  There 
is  no  swelling,  but  loss  of  function  and  ankylosis  frequently  follow. 

The  majority  of  cases  of  gonorrheal  arthritis  appears  during  the  latter 
weeks  of  the  acute  stage  of  the  disease.  The  condition  also  appears  in 
the  subacute  or  chronic  cases. 

There  is  usually  no  difiiculty  in  making  a  diagnosis,  even  without  a 
bacteriolo2[ic  examination.  The  first  steo  is  to  examine  the  urethra 
for  pus  and  the  urine  for  clap  shreds,  and  then  stain  for  the  gonococcus. 
The  only  form  of  acute  arthritis  which  requires  differentiation  is  artic- 
ular rheumatism. 

Both  of  these  may  begin  as  potyarticular  lesions.  Acute  rheumatism 
is  more  apt  to  involve  the  smaller  joints  of  the  fingers  or  toes  than  is  the 
gonorrheal  form.  In  many  cases  the  local  signs  are  so  similar  in  their 
severity  as  to  make  a  differentiation  impossible.  The  presence  of  a 
local  gonorrheal  infection  should  be  sought  for.  If  the  gonococcus  is 
found  in  the  joint  exudate,  the  diagnosis  is  confirmed.  This  latter  is 
unfortunately  a  very  difficult  mode  of  diagnosis,  and  often  results 
negatively. 

Gonorrheal  arthritis  is  more  frequently  monarticular  than  is  the 
ordinary  acute  form;  there  is  also  an  absence  of  cardiac  or  other  serous 
comphcations  in  the  gonorrheal  form,  and  a  greater  tendency  to  early 
ankylosis. 

In  the  more  chronic  forms  of  gonorrheal  arthritis  without  much 
effusion  and  no  tendency  to  ankylosis,  the  differentiation  from  chronic 
rheumatoid  arthritis  is  very  difficult.  The  most  important  point  is  to 
find  the  primary  focus  in  the  gcnito-urinary  tract. 

Secondary  Acute  Arthritis  by  Extension. — This  form  of  acute 
arthritis  occurs  both  in  adults  and  children.  The  diagnosis  presents  no 
difiiculty.  Even  in  cases  of  this  form  of  arthritis,  following  an  acute 
osteomyehtis  of  the  upper  end  of  the  femur  or  similar  primary  foci^  the 

'  Holt:   "Medical  Record,"  March  ii,  1905. 


DISEASES    OF   THE    BONES    IN    GENERAL.  6ll 

joint  symptoms  are  so  severe  as  to  completely  predominate  the  clinical 
picture. 

The  exudate  is  usually  purulent,  and  contains  the  same  organisms  as 
those  which  have  produced  the  primary  focus. 

Such  secondary  forms  of  arthritis  may  follow  (a)  infection  of  the 
bones  forming  the  joint  (acute  pyogenic  osteomyelitis) ;  (6)  phlegmon  or 
erysipelas,  or  even  lymphangitis  around  the  joint;  (c)  a  suppurative 
bursitis  or  tenosynovitis  in  the  vicinity  of  the  joint,  where  such  structures 
normally  communicate  with  the  articulation;  (d)  penetrating  wounds 
or  operations  upon  the  joints.  Clinically  the  picture  is  that  of  a  severe 
arthritis  accompanied  by  marked  constitutional  disturbances.  The 
primary  cause  can  usually  be  ascertained. 

Chronic  Arthritis. 

Although  the  division  into  acute  and  chronic  arthritis  seems  an  un- 
satisfactory one  from  a  pathologic  standpoint,  it  appears  to  correspond 
in  the  majority  of  cases  to  the  more  important  clinical  signs,  such  as 
mode  of  onset,  local  findings,  etc.  We  shall  see,  however,  that  some  of 
the  forms  of  arthritis  which  are  usually  spoken  of  as  chronic,  i.  e.,  slow 
and  progressive  in  their  course,  begin  quite  acutely.  For  example,  there 
is  a  group  of  cases  of  arthritis  deformans,  which  have  an  acute  onset  and 
course,  becoming  gradually  chronic.  Similar  exceptions  are  found  in 
some  of  the  other  groups,  such  as  acute  forms  of  tuberculous  and  gouty 
arthritis.  These  occur,  however,  rather  infrequently,  and  with  a  little 
consideration  of  the  chief  diagnostic  features  of  each  individual  case,  they 
can  generally  be  placed  under  one  or  the  other  heading. 

Tuberculosis  of  Joints. — To  this  cause  can  be  ascribed  a  large 
percentage  of  cases  of  chronic  joint  disease,  and  in  the  examination  of 
such  patients,  especially  in  early  life,  this  form  of  arthritis  must  always  be 
thought  of. 

As  in  many  other  joint  diseases  a  knowledge  of  the  pathology  is  a 
most  valuable  adjunct  in  making  a  correct  diagnosis.  The  disease  may 
appear  primarily  (a)  in  the  bone,  called  the  primary  osteal  form,  and 
then  either  invade  the  joint,  or  cause  paraarticular  abscesses  without 
any  involvement  of  the  joint;  or  (b)  its  first  manifestations  are  in  the 
synovial  membrane,  called  the  primary  synovial  form,  the  bone  being 
involved  after  erosion  of  the  articular  cartilage.  In  general,  the  primary 
synovial  is  more  frequent  than  the  primary  osteal  form.  In  tlio  hip  and 
elbow,  the  reverse  is  the  case. 

Clinically  there  are  three  forms,  viz. : 

(a)  A  tuberculous  hydrops.     A  slow  accumulation  of  serous  exudate 


6l2  THE    EXTREMITIES. 

takes  place  in  the  joint.  Quite  rarely,  this  form  may  pursue  the  acute 
course  referred  to  above,  the  clinical  picture  greatly  resembling  that  of 
an  acute  rheumatic  arthritis.  Accompanied  by  fever,  pain,  and  swell- 
ing, several  joints  may  be  involved. 

(b)  The  fungus  form.  In  this,  there  is  a  gradually  increasing  en- 
largement of  the  joint  with  pain,  contractures,  and  slight  increase  of 
evening  temperature. 

(c)  Empyema  of  a  joint.  In  this  the  joint  also  enlarges  slowly,  and 
contains  a  considerable  amount  of  tuberculous  pus. 

The  chief  diagnostic  features  of  tuberculosis  of  the  joints  are  as 
follows : 

1.  Pain. — This  varies  greatly,  often  being  quite  severe,  while  at  other 
times  it  is  of  a  dull,  aching  character.  The  pain  is  usually  referred  by 
the  patient  to  the  joint  involved,  but  it  may  be  felt  as  in  the  case  of  a 
tuberculous  hip-joint  in  the  knee.  The  pain  is  often  more  marked  at 
night,  the  exacerbations  causing  patients  to  cry  out  in  their  sleep. 

2.  Tenderness. — This  is  a  valuable  sign  if  found.  It  can,  of  course, 
only  be  elicited  by  pressure  over  the  ends  of  the  bones  which  form  the 
more  superficial  joints,  like  the  ankle,  knee,  fingers,  wrist,  elbow,  and 
shoulder.  When  present  it  indicates  an  osteal  focus.  In  deep  joints, 
like  the  hip,  it  can  be  elicited  by  tapping  upon  the  knee  (Fig.  431). 

3.  Swelling. — This  is  an  early  sign  in  primar}^  synovial  tuberculosis. 
In  the  primary  osteal  variety  it  does  not  appear  so  early  unless  the  dis- 
ease progresses  rapidly.  The  swelling  is  uniform  (Fig.  438).  All  of 
the  normal  depressions  disappear,  and  the  muscles  above  and  below  the 
joint  atrophy. 

4.  Loss  of  Function  and  Rigidity. — This  is  one  of  the  earliest  signs. 
The  limitation  of  movement  is  marked  in  all  directions,  every  movement 
being  accompanied  by  pain.  In  a  primary  synovial  lesion,  the  move- 
ments may  at  first  be  but  little  impaired  and  are  painless.  As  soon,  how- 
ever, as  the  bone  is  involved,  the  limitations  of  motion  and  the  pain 
become  quite  marked. 

5.  Position  of  the  Limb. — This  is  often  quite  characteristic,  and 
varies  with  the  stage  of  the  disease  and  the  individual  joint  involved. 
This  symptom  will  be  referred  to  in  connection  with  the  special  joints. 

6.  Onset  and  Course. — As  a  rule,  joint  tuberculosis  begins  insidiously, 
often  weeks  to  months  after  a  trauma.  Its  course  varies  according  to  the 
virulence  of  the  disease  and  the  treatment  received.  Deformities  are  a 
frequent  sequela.  The  contents  of  the  joint  may  penetrate  the  capsule  in 
one  or  more  places  and  form  paraarticular  abscesses,  which  gradually 
reach  the  surface  of  the  limb  and  either  form  subcutaneous  swellings,  or 


DISEASES    OF   THE    JOINTS    IN    GENERAL.  613 

the  pus  is  evacuated,  sinuses  forming  with  typical  tuberculous  bluish, 
undermined  edges  and  lined  by  flabby,  often  caseous,  granulations. 

7.  Family  and  Personal  History. — It  is  of  great  importance  in  the 
diagnosis  of  joint  tuberculosis  to  secure  an  accurate  family  history  in 
order  to  ascertain  if  possible  any  hereditary  tendency.  In  the  same 
manner,  information  should  be  secured  as  to  the  occurrence  of  tubercu- 
lous lesions  elsewhere,  such  as  caseating  lymph-nodes  (Fig.  429),  other 
osseous,  cutaneous  or  pulmonary  foci.  A  pleurisy  with  effusion  is  often  . 
of  tuberculous  origin. 

8.  Temperature. — As  a  rule,  there  is  but  httle,  if  any,  rise  of  tempera- 
ture. If  any  exist  it  occurs  toward  evening.  At  times  one  encounters 
cases  with  considerable  fever.  These  are  usually  the  result  of  a  mixed 
infection. 

g.  X-ray. — The  3c-ray  is  of  considerable  value  in  the  diagnosis  of 
tuberculous  lesions,  but  unfortunately  it  only  gives  positive  information 
at  a  rather  advanced  stage.  This  is  due  to  the  fact  that  skiagraphs  of 
a  tuberculous  joint  will  only  show  absence  of  normal  shadow,  i.  e.,  a 
defective  clear  area  in  the  plate,  when  the  bone  itself  has  been  affected. 
Its  use  will  be  referred  to  again  in  the  diagnosis  of  tuberculosis  of  the 
individual  joints.  In  very  doubtful  cases,  a  skiagraph  should  be  made, 
since  it  will  often  aid  in  differentiating  advanced  tuberculosis  from, 
arthritis  deformans  and  chronic  rheumatoid  arthritis,  although  even  here 
there  is  a  chance  for  error. 

10.  Tuberculin  Test. — The  diagnostic  value  of  tuberculin  has  been 
the  subject  of  considerable  discussion  of  recent  years,  and  the  general 
opinion  is,  that  it  is  too  unreliable  a  diagnostic  agent  to  be  depended 
upon.  There  are  some  ^  who  beheve  it  is  of  great  aid  in  the  diagnosis  of 
tuberculous  joints,  but  this  opinion  is  not  shared  by  the  profession  in 
general. 

Differential  Diagnosis. — Tuberculosis  of  a  joint  must  be  differen- 
tiated from  a  simple  non-tuberculous  joint  effusion,  from  chronic  gonor- 
rheal and  syphihtic  arthritis,  from  chronic  rheumatoid  arthritis  and 
arthritis  deformans. 

Chronic  Serous  Synovitis,  i.  e.,  a  Non-tuberculous  Joint  Affection. — 
This  usually  begins  acutely  after  an  injury,  and  either  persists,  or  dis- 
appears, to  recur  from  time  to  time.  It  may,  however,  greatly  resemble 
tuberculosis  if  it  begins  insidiously,  causing  a  gradually  increasing  pain- 
less swelling  of  the  joint.  It  is  chiefly  a  disease  of  adults,  so  that  it 
would  rarely  come  into  question  in  the  diagnosis  of  joint  disease  in  chil- 
dren.    In  adults  it  most  often  afl"ects  the  knee.     There  is  an  absence  of 

'  W.  S.  Baer  and  H.  W.  Kennard:  "Johns  Hopkins  Hosp.  Bull.,"  Jan.,  1905. 


6 14  THE    EXTREMITIES. 

bone  tenderness,  of  limitation  of  motion,  of  pain,  and  of  rigidity  so  fre- 
quently found  in  tuberculosis.  The  disease  is  not  progressive;  it  tends 
to  improve  spontaneously.  The  hydrops  often  disappears  and  recurs. 
There  is  no  formation  of  particular  abscesses  or  sinuses. 

Chronic  Gonorrheal  Arthritis.- — In  this  form  of  arthritis,  the  history 
of  its  having  begun  acutely,  and  then  becoming  chronic,  together  with 
the  finding  of  evidences  of  an  old  gonorrheal  infection,  are  of  great  value. 
There  is  also  a  greater  amount  of  paraarticular  thickening,  and  more  of  a 
tendency  to  ankylosis  at  an  earlier  stage  than  is  the  case  in  tuberculosis. 

Arthritis  Deformans. — This  disease  must  be  considered  from  the 
fifteenth  year  on,  especially  in  the  elbow-joint.  In  this  form  of  arthritis 
the  ends  of  the  bones  are  palpably  enlarged,  and  the  capsule  feels  harder 
and  firmer  than  in  tuberculosis.  Arthritis  deformans  also  runs  a  much 
slower  course,  and  is  seldom  accompanied  by  pain.  It  is  also  more  apt  to 
affect  multiple  joints. 

Chronic  Serous  Synovitis  (Chronic  Articular  Hydrops). — This 
form  of  chronic  arthritis  is  usually  the  sequela  or  outgrowth  of  an  acute 
attack.  The  most  frequent  cause  is  an  injury,  i.  e.,  a  simple  sprain  or 
distortion  of  the  joint.  It  may,  however,  appear  in  a  gradual  manner 
without  any  apparent  cause.  In  those  cases  in  which  it  directly  follows 
an  injury,  the  diagnosis  is  not  so  difficult.  There  is  a  history  of  an  in- 
jury followed  by  an  acute  swelling,  which  has  either  persisted  or  has 
disappeared,  or  has  recurred  from  time  to  time.  To  the  latter  clinical 
variety  the  term  intermittent  articular  hydrops  has  been  given.  It  has 
also  been  called  recurrent  effusion. 

Where  the  joint  swelling  has  persisted  after  an  injury,  without  inter- 
vals during  which  the  exudate  has  disappeared,  the  case  may  greatly  re- 
semble a  synovial  tuberculosis.  In  the  latter,  however,  there  is  a  greater 
amount  of  thickening  of  the  capsule,  and  often  a  clear  history  of  tuber- 
culosis in  the  family,  or  foci  to  be  found  elsewhere  in  the  body.  The 
course  of  a  chronic  serous  synovitis  is  also  more  gradual,  i.  e.,  it  ex- 
tends over  a  longer  period.  It  is  also  characterized  by  an  absence  of 
fever,  an  almost  painless  course,  only  a  slight  crepitus,  and  an  absence  of 
pain  on  pressure. 

In  the  second  form  of  chronic  serous  synovitis,  i.  e.,  where  it  appears 
gradually  without  apparent  cause,  the  diagnosis  is  even  more  difficult. 
The  joint  may  be  filled  with  papillomatous  growths  or  converted  into  a 
lipoma  arborescens. 

In  the  majority  of  cases  the  disease  involves  the  loiee-joint,  then  the 
elbow,  ankle,  and  wrist.  The  joints  are  more  movable  than  those  of 
chronic  articular  rheumatism,  and  there  is  no  chansre  in  the  cartilages 


DISEASES    OF    THE    JOINTS    IN   GENERAL. 


615 


and  bones  as  in  an  arthritis  deformans.     There  is  a  gradually  increasing 
loss  of  function,  and  an  accompanying  accumulation  of  fluid. 

Arthritis  Deformans. — This  form  of  chronic  arthritis  has  been 
wrongly  called  rheumatic  gout,  chronic  rheumatic  arthritis,  rheumatoid 
arthritis,  osteo-arthritis,  drv'  arthritis,  and  chronic  articular  rheumatism. 
We  now  know  that  it  is  a  clinical  entity  characterized  by  a  fibrous  degen era- 


\ 


Fig.  413. — Anterior  View  of  a  Case  of  Ar- 
thritis Deformans  in  a  Boy  of  Ten 
(Same  as  shown  in  Fig.  414). 

Note  the  characteristic  rigidity  and  deformities 
of  the  wrists,  elbows,  fingers,  and  knees. 


Fig.  414. — Lateral  View  of  Case  of  .\rthritis  De- 
formans IN  A  Boy  of  Ten. 
Note  the  enlargement  of  the  lower  end  of  the  femur 
and  the  characteristic  deformities  in  the  elbow-  and  wrist- 
joints  and  in  the  fingers.  The  spine  could  not  be  ex- 
tended further  than  is  shown  in  the  illustration,  as  a 
result  of  the  same  process. 


tion  in  the  svnovial  membranes  and  periarticular  structures,  as  well  as  by 
atrophic  and  hypertrophic  changes  in  the  bone.     It  is  most  common  in 
old  age.     According  to  some,  it  is  of  infectious  origin,  while  others  be- 
lieve it  to  be  the  result  of  changes  in  the  central  nervous  system. 
There  are  five  clinical  forms,  according  to  Osier  and  MacRae:^ 
I.  Heberden's  nodes.    Nodosities  develop  gradually  at  the  sides  of 

'  "Journal  of  the  American  Medical  Assn.,"  Jan.  2,  1904. 


6i6 


THE   EXTREMITIES. 


the  distal  phalanges  of  the  fingers  about  the  thirtieth  to  the  fortieth  year. 
The  larger  joints  are  rarely  involved,  and  the  nodes  seldom  cause  any 
symptoms. 

2.  Polyarticular  or  general  progressive  form.  It  may  begin  acutely 
with  symptoms  like  an  acute  articular  rheumatism.  The  chronic  form  is 
themore  frequent,  and  the  joints  are  involved  symmetrically,  usually  those 
of  the  hands  first,  then  the  knees,  hips,  feet,  and  other  articulations. 
There  is  a  variable  amount  of  pain.  In  some  it  is  very  severe,  in  others 
scarcely  noticed.     The  pain  is  accompanied  by  more  or  less  swelling  of 


Fig.  415. — Dislocation  of  Both  Wrists  due  to  Marked  Arthritis  Deformans. 
The  dislocation  is  more  marked  upon  the  right  than  upon  the  left  side,  and  was  of  the  forward  variety, 
characteristic   deformity  of  the  fingers  is  also  present. 


The 


the  joint.  Creaking  soon  begins,  followed  by  inability  to  move  the 
joint  owing  to  fibrous  ankylosis.  The  muscles  of  the  limb  atrophy,  and 
contractures  of  the  joint  set  in  (Fig.  411). 

3.  The  monarticular  form  chiefly  affects  old  people,  and  is  seen  par- 
ticularly (Osier)  in  the  hip,  knee,  spinal  column,  and  shoulder-joint. 
In  many  the  condition  seems  to  directly  follow  an  injury.  The  local 
signs  and  changes,  viz.,  swelling,  ankylosis,  atrophy,  and  deformity,  are 
the  same  as  in  the  polyarticular  form. 

4,  Vertebral  form.  The  disease  here  causes  a  progressive  ankylosis 
with  resulting  rigidity  of  the  spine.     It  may  be  limited  to  one  region  or  in- 


DISEASES    OF   THE    JOINTS    IN   GENERAL. 


617 


f\ 


volve  the  entire  spine,  causing  inability  to  flex  or  extend  it.  Pressure  on 
the  nerve-roots  may  cause  great  pain,  paresthesia,  and  muscular  atrophy. 

5.  In  children  and  young  individuals.  The  onset  may  be  acute  with 
fever  or  even  chills,  or  gradual  mth  increasing  limitation  of  motion  and 
enlargement  of  the  joints.  In  the  hip  of  children  and  young  adults  it 
produces  outward  rotation,  adduction,  and  flexion  similar  to  coxa  vara, 
under  which  heading  it  ^\'ill  be  considered. 

In  children  this  form  of  chronic  arthritis  is  often  characterized  by 
general  enlargement  of  the 
lymph-nodes  and  spleen,  to 
which  complex  of  symptoms 
the  name  StilVs  disease  has 
been  given. 

There  is  more  involve- 
ment of  the  synovial  mem- 
brane and  soft  parts  of  the 
joint  in  children,  and  less  de- 
struction of  bone  and  carti- 
lage than  in  adults.  The 
diagnosis  of  arthritis  de- 
formans is  in  general  not 
diflicult  in  the  advanced 
stages.  In  the  earlier  period, 
especially  in  the  acute  cases, 
the  diagnosis  is  more  difficult. 
The  chief  forms  of  arthritis 
from  which  it  must  be  dif- 
ferentiated are  the  following : 

From  Acute  Articular 
Rheumatism. — The  pain  and 
swelling  are  usually  more 
marked  than  in  arthritis  de- 
.  formans.     The  disease  rarely 

disappears  in  a  joint  to  reappear  in  another  one,  a  phenomenon  so  char- 
acteristic of  rheumatism.  The  spine  and  jaw  are  seldom  involved  in 
rheumatism.  The  enlargement  of  the  lymph-glands  speaks  for  arthritis 
deformans,  as  docs  the  absence  of  cardiac  involvement  and  the  failure  of 
the  sahcylatcs.  There  is  also  more  rapid  muscular  atrophy,  and  the 
joint  symptoms  persist,  even  though  the  temperature  falls  in  arthritis 
deformans. 

From  Gonorrheal  Arthritis. — This  may  cause  pain,  swelling,  stiffness, 


Fig.  416. — Marked  Deformities  of  the  Fingers  and 
Wrists  in  a  Girl  of  Sixteen  due  to  Arthritis  De- 
formans. 


6l8  THE   EXTREMITIES. 

and  be  polyarticular.     It  should  always  be  excluded  in  every  case  (see 
page  609). 

Chronic  Articular  Rheumatism. — This  is  characterized  by  the 
gradual  onset  of  pain  and  swelling  in  the  joints.  The  pain  is  very 
liable  to  exacerbations  during  changes  in  the  weather.  In  some  cases 
there  is  but  little  swelling  or  pain,  the  chief  signs  being  stiffness  and 
crepitation  in  the  joints.  The  disease  may  be  limited  to  a  single  joint, 
such  as  the  shoulder,  hip,  or  knee.  There  is  never  any  erosion  of  cartil- 
age or  formation  of  new  bone,  as  in  arthritis  deformans.  The  condi- 
tion is  often  accompanied  by  valvular  lesions. 

Gouty  Arthritis  (Arthritis  Urica,  Podagra). — This  form  of  joint 
disease  may  appear  in  (a)  an  acute,  (b)  a  chronic,  and  (c)  an  atypical 
or  irregular  form.  The  chronic  may  be  the  outgrowth  of  the  acute 
or  appear  gradually. 

Acute  Gout. — In  this  form  there  is  a  sudden  onset  of  severe 
pain  (usually  at  night)  in  the  metatarso-phalangeal  articulation  of  the 
great  toe.  The  cHnical  picture  is  similar  to  that  described  as  char- 
acteristic of  other  forms  of  acute  arthritis,  viz.,  severe  pain,  exquisite  sensi- 
tiveness to  pressure,  redness  of  the  overlying  skin,  fever,  and  swelling 
of  the  joint  with  obhteration  of  the  normal  depressions.  The  tempera- 
ture may  arise  to  103°  F. 

The  symptoms  improve,  only  to  recur  from  time  to  time.  These 
acute  attacks  last  about  a  week.  Suppuration  never  occurs.  After  one 
or  two  attacks  in  one  toe,  the  same  joint  of  the  other  foot  is  apt  to  be 
affected ;  later  it  involves  the  ankle-  or  knee-joints. 

The  diagnosis  usually  presents  no  difficulties.  The  typical  location 
of  the  acute  joint  swelling  in  a  person  who  has  been  complaining  of 
obscure  pains  all  over  the  body,  without  gastro-intestinal  disturbances, 
and  has  been  a  bon  vivant  or  has  led  a  sedentary  hfe,  should  always  lead 
to  the  suspicion  of  its  being  gouty  in  character.  If  the  acute  attack 
occurs  primarily  in  other  joints  than  those  of  the  great  toe,  the  diagnosis 
can  only  be  made  if  tophi  are  found.  These  are  collections  of  uric  acid 
deposited  in  the  external  ear,  the  finger-joints,  and  later  around  the  knee, 
elbow,  etc.  Another  diagnostic  point  in  favor  of  gout  versus  acute 
rheumatic  arthritis  is  the  fact  that  the  output  of  uric  acid  is  greatly  dim- 
inished during  the  attack.  Fever  is  more  constant  in  acute  rheuma- 
tism than  in  gout.  If  limited  to  the  metatarso-phalangeal  joint  of  the 
great  toe  it  must  be  differentiated  from  a  bursitis  (see  page  263). 

Chronic  Gouty  Arthritis. — -This  is  either  an  outgrowth  of  the  attacks 
of  acute  gout  or  may  be  primarily  chronic.  The  toes,  and  later  the  fingers, 
ankles,  knees,  and  elbows,  gradually  increase  in  size  and  become  deformed. 


DISEASES    OF   THE    JOINTS    IN    GENERAL. 


619 


These  enlargements  are  accompanied  by  deposits  of  uric  acid  around  the 
affected  joint  capsule  and  in  the  ears.  Ulceration  of  the  skin  over  these 
tophi  may  occur.  Accompanying  these  joint  symptoms  are  often  those 
of  a  chronic  interstitial  nephritis.  These  chronic  cases  can  be  differen- 
tiated from  arthritis  deformans  and  chronic  rheumatism  by  the  presence 
of  tophi  around  the  joints 
and  in  the  ears,  as  well 
as  by  the  constancy  with 
which  the  acute  attacks 
begin  in  the  joints  of  the 
great  toe. 

Atypical  or  Irregular 
Form. — -This  is  a  group 
of  cutaneous,  gastro-intes- 
tinal,  cardiovascular,  ner- 
vous, and  urinary  sym- 
ptoms, which  often  ac- 
company more  chronic 
forms  of  gouty  arthritis, 
or  may  occur  indepen- 
dently of  it. 

Syphilitic  Arthritis. 
Acquired  Syphilis. — (a) 
Secondary  Syphilitic  Ar- 
thritis.— Quite  rarely  an 
acute  swelling,  indicating 
an  effusion  into  the  larger 
joints,  occurs  during  the 
secondary  stage.  It  is 
characterized  by  pain  and 
effusion  in  one  or  more  of 
the  larger  joints.     Usually 

the  knee  is  the  only  joint  involved.  The  diagnosis  can  be  made  from 
the  fact  that  the  arthritis  appears  almost  simultaneously  with  the  first  cu- 
taneous eruption,  i.  e.,  about  seven  to  eight  weeks  after  the  initial  lesion. 
The  joint  swelhng  disappears  rapidly  after  antisyphilitic  treatment. 

(&)  Tertiary  or  Chronic  Syphilitic  Arthritis. — During  this  stage  a 
form  of  arthritis  occurs  which  is  most  difficult  to  recognize.  It  resem- 
bles a  tuberculous  arthritis  so  closely,  that  at  times  a  differentiation  can 
only  be  made  by  the  administration  of  iodids  and  mercury  or  by  opening 
the  joint.     In  the  latter  case  one  would  see  gummata  in  the  synovial 


Fig.  417. — Tabetic  Hip-joints. 

Note  the  enormous  enlargement  of  the  gluteal  region,  due  to 

increased  size  of  the  articular  ends  of  the  bone. 


620  THE   EXTREMITIES. 

membrane  or  in  the  articular  ends  of  the  bone.  The  gummata  are  much 
larger  and  firmer  than  a  tubercle,  and  are  never  caseated.  If  the  disease 
is  far  advanced,  ankylosis  occurs,  and  antisyphilitic  remedies  produce 
no  improvement. 

The  history  of  a  preceding  syphilitic  infection  and  the  presence 
of  evidences  of  the  disease  elsewhere,  as  well  as  the  results  of  the  thera- 
peutic tests,  are  the  chief  factors  in  making  a  diagnosis.  The  destruction 
of  cartilage  is  seldom  as  extensive  as  in  a  tuberculosis  and  the  tendency 
to  deformity  is  far  less  marked  than  in  tuberculosis.  The  absence 
of  a  primary  focus  of  tuberculosis,  or  of  a  family  history  of  this  disease, 
will  also  aid  in  the  diamosis. 


'^^~^-'  ■  ...  — -^   ■ "— ■  "  ---«s«i 


Fig.  418. — Charcot  Knee-joints. 
The  illustration  shows  a  typical  case  of  disease  of  the  knee-joint  occurring  in  tabes  dorsalis  or  locomotor 
ataxia,  to  which  the  name  arthropathia  tabetique  of  Charcot  has  been  given.     Note  the  enormous  enlargement 
of  the  lower  ends  of  both  femorje,  and  the  backward  displacement  of  both  tibia. 

The  arthritis  referred  to  above  is  that  due  to  the  presence  of  primary 
gummata  in  the  synovial  membranes.  Another  form  is  that  which  is 
secondary  to  a  gummatous  osteomyelitis,  and  is  not  so  difficult  to 
recognize,  owing  to  the  enlargement  of  the  ends  of  the  long  bones  pre- 
ceding the  arthritis. 

The  latter  is  most  often  found  in  the  knee.  Periarticular  gummata 
also  occur  as  localized  tumors  from  hazelnut  to  walnut  size,  with  but 
few  subjective  symptoms.  It  must  be  differentiated  from  the  fibroma- 
tous  form  of  tuberculous  arthritis.     Both  of  these  conditions  are  very  rare. 

(c)  Arthritis  in  Hereditary  Syphilis. — This   appears   usually   in  a 


DISEASES    OF   THE    JOINTS    IN   GENERAL. 


621 


gradual  manner,  either  with  or  without  accompanying  primary  bone 
involvement.  It  most  often  alTects  the  knees,  but  may  involve  the 
wrists  and  elbows.  It  seldom  appears  before  the  sixth  year.  There 
is  considerable  swelling  and  thickening  of  the  capsule,  the  latter 
in  the  form  which  is  secondary  to  bone  disease.  Nocturnal  pains 
are  complained  of.  The  epiphysis  is  often  enlarged  and  may  be 
entirely  separated  from  the  shaft.  The  loss  of  function  in  such  a  joint 
often  gives  rise  to  a  condition  known  as  pseudo- paralysis.  Pus  forma- 
tion is  rare.  The  suspicion  of  hereditary  syphilis  should  always  be 
aroused  if  an  apparently  ichopathic,   almost  painless,   spindle-shaped 


Fig.  4ip. — Anterior  View  of  a  Tabetic  or   Charcot 
Knee-joint,  Which  Had  Been  Suspected  to  Be  a 
Sarcoma  of  the  Femur. 
This  is- the  same  case  as  shown  in  Figs.  420  and  421. 


Fig.  420. — View  from  Right  Side  of  En- 
largement of  the  Lower  End  of  Femur 
and  Knke-joint  in  a  Case  of  Tabetic 
Arthritis. 
Same  case  as  shown  in  Figs.  419  and  421. 


swelhng  of  the  larger  joints,  especially  the  knee  or  elbow,  appears  in  a 
child,  accompanied  by  loss  of  function  of  the  arm  or  leg.  The  cornea, 
teeth,  skull,  and  other  epiphyses  should  be  examined,  and  a  careful  history 
of  the  family  and  the  infant's  previous  eruptions,  coryza,  etc.,  should  be 
inquired  into.  These  joints  improve  rapidly  after  antisyphilitic  treatment. 
Neuropathic  Arthritis. — This  occurs  after  middle  life  with  such 
comparative  frequency  that  the  possibility  of  an  obscure  joint  affeclion 
being  either  of  tabetic  or  syringomyelic  origin  must  be  constantly  borne 
in  mind. 


622 


THE    EXTREMITIES. 


These  two  forms  of  arthropathy,  viz.,  those  due  to  syringomyeha  and 
to  tabes,  differ  somewhat  in  their  dinical  appearance. 

(a)  Arthritis  Tabetica  (Arthropathie  Tabetique,  Arthritis N euro genica) . 
— The  cKnical  history  varies  greatly.  In  some  cases  the  joint  swelling 
appeared  suddenly  after  a  shght  injury,  and  has  persisted  in  spite  of  all 
treatment.  In  other  cases  the  onset  of  the  swelling  was  gradual,  and 
attracted  the  attention  of  the  patient  only  when  it  became  quite  marked 
and  was  accompanied  by  deformity  such  as  subluxation,  or  by  loss  of 

function  due  to  laxity  of  the  Hg- 
aments.  The  joints  most  fre- 
quently affected  are  the  knee, 
hip,  and  ankle,  in  the  order 
named.  In  any  case  of  joint 
disease  in  middle-aged  or  old 
persons,  in  which  there  has  been 
a  rapid  painless  swelling  of  the 
joint,  the  possibihty  of  tabes 
must  be  considered  and  a  search 
for  the  classic  symptoms  made. 
These  are  so  fully  described  in 
all  of  the  text-books  on  internal 
medicine  and  neurology  that  it 
will  only  be  necessary  to  men- 
tion the  lightning-like  pains 
along  the  back  of  the  lower 
limbs,  the  absence  of  the  patellar 
reflexes,  the  swaying  of  the  body 
when  standing  erect  with  eyes 
closed,  ataxic  gait,  the  Argyll- 
Robertson  pupils,  the  bladder 
and  rectal  paralysis,  and  finally 
the  disturbances   of  cutaneous  sensation. 

In  the  most  typical  cases,  the  knee  or  ankle  is  enormously  enlarged, 
there  is  marked  crepitus  on  manipulation,  and  the  ends  of  the  femur  and 
tibia  can  be  felt  to  be  markedly  enlarged.  The  latter  may  be  so  great 
that  in  the  case  shown  in  Fig.  422  the  patient  was  referred  to  the  writer 
with  the  diagnosis  of  osteosarcoma  of  the  lower  end  of  the  femur. 
Accompanying  the  joint  sweUing  there  is  often  a  subluxation  of  one  of 
the  bones  of  the  joint  (Fig.  418).  In  many  of  the  cases,  the  painless 
abnormal  mobility  of  the  joint  is  the  most  characteristic  feature.  This 
symptom  and  the  rough  crepitus  are  the  chief  factors  in  the  diagnosis  of 


Fig.  421. — Tabetic  Knee-joint. 
The  illustration  shows  the  enormous  enlargement 
of  the  lower  end  of  the  femur  as  a  result  of  trophic  dis- 
turbances and  the  abiUty  to  produce  abnormal  abduc- 
tion in  the  knee-joint. 


DISEASES    OF   THE    JOINTS    IN    GENERAL.  623 

tabetic  disease  of  the  hip-joint.  The  swelHng  may  disappear  entirely  in 
some  cases,  and  then  recur  from  time  to  time.  In  other  cases  there  is  no 
swelHng  at  any  time,  but  a  tendency  to  the  formation  of  osteophytes  in 
the  joint  capsule. 

The  principal  forms  of  arthritis  from  which  it  must  be  differen- 
tiated are  tuberculosis  and  arthritis  deformans.  In  neither  of  these  is 
the  swelling  as  painless  as  in  tabes. 


Fig.  422. — X-RAY  OF  a  Tabetic  Knee-joint. 
Note  the  hypertrophic  condition  of  the  internal  condyle  of  the  femur  which  .simulated  a  neoplasm. 

Arthritis  deformans  often  affects  many  joints,  especially  the  smaller 
ones,  and  there  is  overgrowth  of  bone  (hypertrophic  form)  with  tendency 
to  ankylosis.  Tuberculosis  is  infrequent  at  the  time  of  hfe  when  tabes 
appears.  The  joint  swelling  is  seldom  as  marked  as  in  tabes,  and  the 
capsule  is  usually  tliicker.  The  swelHng  leads  to  more  or  less  fixation 
of  the  joint  in  tuberculosis,  and  not  to  abnormal  mobility  as  in  tabes. 
The  previous  history  of  the  two  affections  and  the  examination  for  the 
nervous  symptoms  of  tabes  will  clear  up  any  doubts. 


624 


THE   EXTREMITIES. 


(b)  Syringomyelia. — This  form  of  neuropathic  arthritis  differs  from 
that  of  tabes  in  chiefly  affecting  the  joints  of  the  upper  extremity.  There 
are  usually  two  forms:  (a)  As  in  tabes,  there  may  be  a  sudden  onset 
with  joint  swelling  after  an  injury. 

In  other  cases  the  swelhng  appears  very  slowly.  In  both  instances 
the  shoulder  or  elbow  is  most  often  affected.  The  sweUing  itself  is 
enormous,  and  the  abnormal  mobility  and  rough  crepitus  on  manipula- 
tion very  marked. 

(b)  In  the  second  form,  the  most  striking  feature  is  the  tendency  to 
recurrent  dislocation,  most  often  of  the  shoulder-joint.     This  may  have 

appeared  like  the  ordinary  form  of 
dislocation  after  an  injury.  The 
injury,  however,  is  often  of  a  trivial 
nature.  Suspicion  should  be 
aroused  in  every  such  case,  when 
the  dislocation  tends  to  recur  upon 
the  slightest  amount  of  manipula- 
tion. This  tendency  to  disloca- 
tion, accompanied  by  the  enor- 
mous distention  of  the  capsule, 
the  painless  course,  and  the  rough 
grating  sensation  obtained  on 
manipulation,  should  cause  an  ex- 
amination for  the  other  symptoms 
of  syringomyelia  to  be  made. 
These  are  the  occurrence  of  pain- 
less infections  about  the  fingers 
and  an  absence  of  temperature 
and  pain  sense,  so  that  the  patient 
will  burn  or  freeze  his  fingers 
without  being  conscious  of  it. 
In  80  per  cent,  of  the  cases  of  tabes  the  arthropathy  is  confined  to 
the  lower  extremity,  while  in  syringomyelia  the  same  is  true  for  the 
upper  extremity.  The  clinical  picture  of  both  is  similar  (Figs.  419 
and  423),  viz.,  enormous  swelling,  relaxation  of  the  capsule  and  liga- 
ment permitting  of  abnormal  mobility  or  of  complete  or  incomplete 
dislocations  taking  place.  Fractures  near  the  affected  joint  are  more 
frequent  in  tabes.     Both  run  an  almost  painless  course. 

Hemophiliac  and  Scorbutic  Joints. — Both  of  these  may  appear 
in  an  acute  and  chronic  manner. 

The  symptoms  of  both  are  practically  the  same,  the  chief  difference 


Fig.  423. — Syringomyelic  Disease  of  the  Elbow 
JOINT  (E.  Graf). 


DISEASES    OF   THE    JOINTS    IN    GENERAL. 


625 


being  in  the  history  of  the  case.  In  the  acute  form  there  is  pain, 
fever,  and  marked  swelhng  of  the  joint.  These  all  disappear,  but  may 
recur.  In  less  severe  cases  there  is  only  moderate  swelling  and  pain, 
but  no  fever. 

In  the  chronic  form  the  joint  has  passed  through  a  number  of  the 
acute  or  subacute  attacks  just  described,  but  remains  swollen  with  thick- 
ening of  the  capsule,  evidences  of  fluctuations,  and  enlargement  of  the 
joint  ends  of  the  bones.     Adhe- 
sions   are    often  present,  caus- 
ing considerable  impairment  of 
mobility. 

The  joint  lesions  can  seldom 
be  diagnosed  as  accompanying 
a  general  or  scorbutic  condition, 
or  as  occurring  as  a  part  of  a 
general  tendency  to  hemorrhage 
(hemophiha),  without  an  accu- 
rate history  and  the  thorough 
examination  of  the  body  in  gen- 
eral. 

In  the  hemophiliac  joints 
there  is  usually  a  previous  his- 
tory, or  some  other  obstinate 
hemorrhage  from  slight  causes. 
The  patients  are  often  pale  and 
anemic.  The  aspiration  of  the 
joint  effusion  shows  it  to  be 
pure  blood.  Since  blood,  even 
in  microscopic  quantities,  is 
rarely  observed  in  any  other 
form  of  non-traumatic  arthritis, 
its  presence  should  lead  one 
to  suspect  either  hemophilia, 
scorbutus,    or    a  new    growth. 

In  scurvy  (scorbutus)  there  is  usually  a  history  of  an  absence  of  some 
normally  necessary  factor  in  the  diet,  whether  it  occur  in  children  or 
adults. 

In  children  there  is  such  marked  soreness  about  the  loiees  or  ankles 

that  they  cry  out  with  pain  when  lifted,  and  a  condition  of  pseudo-paralysis 

results  from  inability  to  use  the  limbs.     In  adults  the  joint  swelling  is 

the  most  marked  feature,  and  there  is  pain  over  the  affected  tibia  or 

40 


Fig.   424. — View   of  Case  of  Tuberculosis  of  the 
Shoulder-joint  from  Outer  Side,  to  be  Com- 
pared WITH  Normal  Shoulder  shown  in  Fig. 
425- 
Note  the  atrophy  of  the  deUoid  from  disuse,  causing 

the  acromio-clavicular  articulation  to  become  prominent; 

and  also  observe  the  fullness  below  the  coracoid  process, 

due  to  the  thickening  of  the  joint  capsule,  etc. 


626  THE   EXTREMITIES. 

femur.  As  in  children,  the  knee-  and  ankle-joints  are  most  often 
involved. 

In  both  children  and  adults  the  most  important  diagnostic  sign  is  the 
spongy,  swollen,  bleeding  gums,  a  foul  breath,  and  a  tendency  to  sub- 
cutaneous hemorrhages. 

Prompt  improvement  follows  proper  diet.  Epistaxis  is  frequent  in 
adults,  and  there  is  general  anemia.  The  vast  majority  of  hemorrhages 
occur  in  the  knee,  and  most  frequently  in  men.  In  purpura  rheumatica 
the  subcutaneous  hemorrhages  (Fig.  442)  are  usually  a  deciding  factor, 
as  is  also  the  fact  that  many  joints  are  usually  involved. 

In  the  chronic  form  a  scorbutic  or  hemophiliac  joint  may  resemble 
a  tuberculous  arthritis,  but  there  is  usually  some  rise  of  temperature  in 
the  latter  (99°  to  99.5°  F.  in  the  afternoon).  The  course  of  a  tuberculosis 
is  also  more  progressive,  and  there  are  never  any  sudden  exacerbations 
or  remissions.  When  ankylosis  exists  the  diiTerentiation  from  chronic 
rheumatic  or  tubercular  joints  is  impossible,  without  a  complete  history. 

Tumors  of  Joints. 

These  are  very  rare,  and  are  chiefly  benign  in  character,  al- 
though a  few  cases  of  sarcomata  of  the  larger  joints  (Fig.  408)  have 
been  observed.  The  most  common  of  the  benign  forms  are  the  joint 
lipomata  first  described  by  Volkmann  in  1875.^  These  cases  are  true 
lipomata,  usually  developing  beneath  the  synovial  membrane,  i.  e.,  ex- 
traarticular. They  differ  from  a  condition  known  as  lipoma  arborescens, 
in  which  there  is  an  excessive  deposit  of  fat  in  the  normal  joint  villi. 
Both  of  the  conditions  just  referred  to  occur  most  frequently  in  the 
knee-joint,  but  cases  of  its  occurrence  in  the  elbow  and  ankle  have  been 
described. 

The  tumor  extends  into  the  joint,  either  carr}ang  the  synovial  mem- 
brane or  breaking  through  the  latter.  The  principal  symptom  in  these 
cases  is  a  painless  enlargement  of  the  joint.  The  swelling  is  soft  and 
doughy. 

Neuralgic  or  Hysterical  Joints. 

This  form  of  joint  affection  is  found  in  neurotic  persons,  and  may 
simulate  genuine  disease.  The  conditions  may  follow  an  insignificant 
injury,  usually  of  the  hip  or  knee,  but  it  may  appear  in  any  joint  after 
an  injury  and  be  made  the  basis, for  damage  suits.  Any  attempt  at 
movement  causes  great  pain. 

The  joint  motions  are  apparently  restricted  in  all  directions,  but 
if  the  patient's  attention  is  diverted  or  if  he  is  anesthetized,  all 
limitation  of  movement  disappears. 

^  Biochitzk)-:  •' Beitrage  zur  klinischen  Chirurgie,"  vol.  xxiii. 


DISEASES    OF    THE    INDIVIDUAL    JOINTS. 


627 


The  joint  is  often  swollen  and  sensitive,  as  well  as  fixed.  Intermit- 
tent hydrops  may  occur  in  such  joints.  In  cases  of  long  duration  there 
is  some  atrophy  of  the  muscles  above  and  below  the  joint  (Figs.  258  and 
259),  as  a  result  of  non-use.  There  is  seldom  any  rise  of  local  temper- 
ature, but  even  this  may  exist. 

Accompan3dng  the  joint  symptoms  are  other  signs  of  hysteria  both 
in  children  and  adults,  and  in  men  as  well  as  in  women. 


DISEASES  OF  THE  INDIVIDUAL  JOINTS. 

The  clinical  picture  of  both  acute  and  chronic  arthritis  possesses  cer- 
tain variations  according  to  the  joint  involved.  These  depend  upon 
the  relations  of  the  capsule  to  the  overlying  parts,  as  well  as  upon  the 
accessibihty  of  the  individual  joint  to  direct  manipulation.  For  ex- 
ample, the  capsule  of  the  knee-joint  lies  so  close  to  the  surface  and 
extends  over  so  great  an  area,  that  the  recognition  of  changes  both 
within  and  external  to  the  joint  is  much  easier  than  is  the  case  with  such 
articulations  as  the  shoulder  and  hip.  In  the  case  of  the  shoulder  but 
little  of  the  capsule  Kes  close  to  the  surface,  while  in  the  hip,  the  depth  of 
the  joint  prevents  any  direct  recognition  of  changes. 

It  is  therefore  important  to  be  able  to  search  for  certain  clinical 
characteristics  of  each  individual  joint. 

The  following  table  may  be  of  some  assistance: 


Swelling  First  Appears. 

Shoulder Anteriorly  between  coracoid 

and  head  of  humerus. 
Elbow On  both  sides  of  olecranon. 

Wrist On  dorsum. 

Finger-joints  . . .On  dorsum. 
Sacroiliac On  back  of  joint. 

Hip Invisible  until  later,  then  in 

front. 
Knee On  all  sides  of  patella. 

Ankle Over  front  of  joint  and" below 

malleoli. 
Tarsal  joints..  .Invisible. 
Toes On  dorsum. 


Pain. 
Over  joint  and 
along  arm. 
Over  joint. 

Over  joint. 
Over  joint. 
Over  joint   and 

along  back 

of  limb. 
Over  joint  and  to 

knee. 
Over  joint. 

Over  joint. 

Over  joint. 
Over  joint. 


Most  Characteristic 
Position. 

Adduction. 


Flexed    at    acute 
right  angle. 


Slight  flexion. 
Flexion. 
No  change. 


Varies  according  to 
stage   (p.  634). 

Flexion,  later  sublux- 
ation of  tibia'. 

Flexion. 


No  change. 
Flexion. 


Shoulder-joint. 
Acute   arthritis,  exclusive    of  the   traumatic  form,  is  infrequent  in 
this  articulation,  and  has  no  special  characteristics.     The  most  com- 


628 


THE    EXTREMITIES. 


mon  forms  of  chronic  inflammation  are  tuberculosis,  rheumatism, 
arthritis  deformans,  and  syringomyelia,  as  well  as  the  various  forms  of 
post-traumatic  ankylosis. 

Tuberculosis  of  the  shoulder- joint  is  a  comparatively  rare  affection. 
It  begins  insidiously  with  pain  on  motion  and  there  is  a  dull  aching 
pain  when  the  limb  is  at  rest.  The  pain  is  often  neuralgic  in  character, 
and  is  always  worse  at  night.  The  shoulder  appears  fuller  in  front,  be- 
tween the  coracoid  and  humerus, 
and  there  is  usually  marked 
atrophy  of  the  deltoid,  so  that 
the  acromion  is  quite  prominent. 
The  arm  is  adducted  to  the  side 
of  the  body.  Abduction,  both 
active  and  passive,  is  difficult, 
and  accompanied  by  pain. 
When  suppuration  occurs,  the 
sinuses  appear  in  the  axilla  and 
over  the  front  and  back  of  the 
joint.  There  is  usually  no  diffi- 
culty in  distinguishing  a  subdel- 
toid bursitis  from  an  arthritis  of 
the  shoulder.  The  two  may 
however  coexist,  especially  in 
tuberculosis. 

Elbow-joint. 
The  majority  of  forms  of 
acute  and  chronic  arthritis  of 
this  joint  are  accompanied  by 
effusion  and  changes  in  the  cap- 
sule. The  swelhng  is  most 
marked  on  either  side  of  the  ole- 
cranon process,  and  the  early  at- 
rophy of  themusclesof  the  arm  and  forearm,  gives  the  joint  enlargement  a 
spindle-shaped  appearance.  If  the  effusion  is  extensive,  fluctuation  may 
be  easily  ehcited  over  the  back  of  the  joint.  The  joint  is  held  rigid  in  a 
flexed  position,  either  at  a  right  or  an  acute  angle.  Pronation  and  supina- 
tion are  greatly  hmited.  If  the  tuberculosis  is  limited  to  the  head  of 
the  radius,  there  is  marked  absence  of  rotary  power  and  localized  swelling. 
Sinuses  are  most  apt  to  be  found  upon  the  posterior  and  lateral  aspects 
of  the  joint. 


Fig.  425. — View  of  Xurmal  Shoulder  prom  Outer 
Side. 
To  be  compared  with  Fig.  424.  (Case  of  tuber- 
culosis of  the  shoulder-joint.)  Observe  the  depression 
below  the  coracoid  process  on  the  normal  side,  as  com- 
pared with  fullness  on  the  diseased  side. 


DISEASES    OF   THE   INDIVIDUAL    JOINTS. 


629 


■Wrist-joint. 
This  joint  lies  so  superficially  that  but  httle  effusion  is  required 
to  obhterate  the  normal  depression  upon  the  back  of  the  wrist.  The 
most  common  affection  of  the  chronic  variety  is  tuberculosis.  In  this 
there  is  swelling  on  the  back  of  the  wrist.  The  wrist-joint  is  stiff,  and  any 
movements  are  accompanied  by  pain.  The  hand  is  held  flexed  on  the 
forearm.     As  in  the  case  of  the  other  joints,  the  degree  of  swelhng  can  be 


Fig.  426. — Tuberculosis  of  the  Shoulder-joint,  showing   the  Limitation  of  Motion  on  the  Dis- 
eased Side,  and  Characteristic  Abduction  Deformity. 
On  the  normal  side  the  arm  could  be  raised  up  easily  to  the  level  of  the  head;  on  the  diseased  side  it  could 
only  be  voluntarily  abducted  from  the  body  about  forty-five  degrees. 


estimated  by  comparing  its  circumference  with  the  joint  of  the  oppo- 
site limb. 

Finger-joints. 
These  arc  frequently  the  scat  of  acule  rheumatic  arlliritis  and  of 
gouty  and  chronic  rheumatic  arthritis,  as  well  as  of  arthritis  deformans. 
Tuberculosis  may  occur  independently  of  an  osteomyelitic  focus,  but  is 
usually  associated  willi  Ihc  latter  (Fig.  398).  The  swelling  is  always 
more  distinct  on  llic  dorsum.  In  acute  forms  tlie  ])osition  is  one  of 
extension,  wliile  in  llie  chronic  forms  llexion  and  lateral  deviation 
are  more  common. 


630 


THE    EXTEEillTIES. 


Special  attention  must  be  called  to  a  form  of  septic  arthritis,  caused 
by  a  bite,  the  teeth  entering  the  metacarpo-phalangeal  joints  while  they 
are  flexed.  They  run  a  subacute  course  and  are  often  overlooked, 
the  case  being  treated  as  one  of  ordinary  subcutaneous  phlegmon. 

Sacroiliac  Joints. 
This  occurs  very  rarely,  and  usually  in  young  adults.     Tuberculosis 

is  practically  the  only  form 
of  disease  of  this  joint. 

Pain  is  felt  by  the 
patient  over  the  articula- 
tion, which  is  often  worse 
at  night.  The  joint  is  also 
sensitive  to  pressure.  The 
pain  radiates  do^^^l  the 
thigh,  and  is  increased 
when  the  patient  sits  do^Mi. 
The  patient  attempts  to 
step  as  hghtly  as  pos- 
sible upon  the  toes  of  the 
diseased  side,  so  that 
limping  is  quite  marked 
and  the  pelvis  compensa- 
torily  lowered.  There  is 
often  swelling  to  be  seen 
and  felt  posteriorly  over 
the  articulation.  When 
the  ihum  is  grasped  on  the 
diseased  side  and  attempts 
made  to  move  it,  the  pain 
in  the  joint  is  greatly  increased.  Abscesses  open  either  posteriorly  or 
burrow  along  the  pelvic  fascia  to  open  in  the  lumbar  or  gluteal  regions, 
in  the  ischiorectal  fossa,  or  even  in  the  inguinal  region. 

Disease  of  this  articulation  must  be  differentiated  from  lumbago, 
sciatica,  from  hip-joint  cHsease,  and  tuberculosis  of  the  sacrum  or  verte- 
bras. It  can  be  differentiated  from  lumbago  by  the  fact  that  the  pain 
is  higher  up  and  is  not  locahzed,  as  in  sacroihac  disease.  In  sciatica 
the  predominant  symptoms  are  pain  over  the  sacrosciatic  notch,  which 
radiates  down  the  back  of  the  thigh  and  then  into  the  foot.  There  is  no 
tenderness  over  the  sacroiliac  joint,  and  the  patient  does  not  hold  the 
pelvis  rigid  or  cry  out  with  pain  when  the  ilia  are  pressed  together. 


Fig.  427. — ^AxTERiOR  View  of  Case  of  Tuberculosis  of  the 

Shouxder-jokt. 

X,  Xormal  shoulder- joint;  T,  tuberculous.    Note  the  prominence 

of  the  diseased  side. 


DISEASES    OF    THE    INDIVIDUAL    JOINTS. 


631 


From  tuberculosis  of  the  spine  sacroiliac  disease  can  be  distinguished 
by  the  fact  that  one  or  more  of  the  spinous  processes  are  prominent, 
and  there  is  marked  reflex  rigidity  higher  up  than  is  the  case  in  sacro- 
iliac disease  when  movement  is  attempted. 

From  coxitis  it  can  be  differentiated  by  the  presence  of  rigidity,  when 
attempts  are  made  to  carry  out  movements  of  the  hip-joint.  The  pain  is 
felt  in  the  hip  or  knee,  and  not  over  the  sacroiliac  joint.  In  diseases  of 
the  latter  joint,  when  the  pelvis  is  fixed,  all  movements  of  the  hip  are  free. 

In  advanced  cases  of 
hip-joint,  sacroiliac,  and 
Pott's  disease,  when  many 
sinuses  are  present  it  is 
often  impossible,  before 
operation,  to  state  the  pri- 
mary source  of  the  pus. 

Diseases  of  the  Hip-joint 
(Coxitis). 

Acute  affections  of  this 
joint  are  infrequent.  The 
acute  arthritis  following  an 
osteomyelitis  of  the  upper 
end  of  the  femur  in  chil- 
dren has  already  been  re- 
ferred to  (page  579  )  and 
will  be  taken  up  later  under 
the  head  of  differential 
diagnosis  of  tuberculosis 
of  the  hip.  Acute  arthritis 
of  the  joint  occurs  during 
all  of  the  infectious  diseases 

mentioned  as  causing  arthritis  (see  page  602).  The  diagnosis  in  such 
cases  can  be  made  {a)  from  the  history  of  the  primary  infection;  {h) 
from  the  presence  of  severe  pain  referred  to  the  hip  or  knee;  {c)  from  the 
marked  limitation  of  movement  of  the  joint,  the  reflex  muscular  spasm 
causing  almost  absolute  fixation;  {d)  from  the  presence  of  fever  and 
other  signs  of  acute  inflammatory  reaction. 

In  some  cases  the  patients  are  not  seen  during  the  acute  stage  of  coxi- 
tis. The  surgeon  is  consulted  on  account  of  a  deformity  resulting  from 
it.  This  may  be  either  in  the  shape  of  an  ankylosis  or  of  a  dislocation. 
The  diagnosis  in  cither  case  rests  upon  the  objective  findings  taken  in 


Fig.  428. — Posterior  \'iew  of  Case  of  Tuberculosis  of  the 
Elbow-joint. 
N,  Normal  arm;   T,  tuberculous.     Note  the  characteristic 
obliteration  of  the  depressions  on  either  side  of  the  olecranon 
process.     (See  Fig.  429.) 


632 


THE   EXTREMITIES. 


conjunction  with  the  previous  histor}^  Such  apparently  spontaneous 
dislocations  following  an  acute  coxitis  have  been  reported  after  ty- 
phoid, scarlatina,  acute  rheumatism,  influenza,  etc. 

Another  form  of  acute  coxitis  to  be  mentioned  is  that  resulting  from 
gonorrhea.     As  is  the  case  in  all  of  the  forms  of  metastatic  gonorrheal 

arthritis,  there  is  an 
early  tendency  to 
marked  ankylosis. 
It  is  most  apt  to  oc- 
cur in  young  adults. 
The  most  impor- 
tant disease  of  the 
hip-joint  is  tubercu- 
losis. It  is  the  one 
from  which  the  ma- 
jority of  the  acute 
forms  must  be  differ- 
entiated, both  at  the 
time  of  the  onset  and, 
if  seen  at  a  later  per- 
iod, after  all  of  the 
acute  symptoms  have 
disappeared. 

Tuberculosis  of 
the  Hip-joint  (Tu- 
berculous Coxitis). 
— The  examination 
of  a  child  or  adult  for 
the  purpose  of  mak- 
ing a  diagnosis  of  this 
common  affection 
should  be  conducted 
in  a  more  or  less  sys- 
tematic manner,  as 
follows : 

I.  Detailed  his- 
tory of  the  case. 

2.  Inspection.  To  determine  (a)  the  presence  of  lameness;  (b)  the 
position  in  which  the  hmb  is  held,  /.  e.,  its  attitude  during  walking, 
standing,  or  upon  lying  down. 

3.  Palpation.     To  determine  (a)  whether  there  is  fixation  of  the  joint, 


Fig.  429. — Tuberculosis  of  the  Elbow-joint. 
Note  the  depressed  scar  in  the  supraclavicular  region  following  an 
operation  for  tuberculous  lymph-nodes  of  the  neck.  This  was  probably  the 
primary  infection,  having  preceded  the  elbow-joint  disease  by  five  years. 
(See  text.)  Observe  the  characteristic  fle.xion  of  the  elbow,  which  occurs 
in  all  diseases  of  the  elbow- joint,  the  forearm  and  hand  being  held  in  a 
position  of  half  supination  and  half  pronation.  Observe  the  prominence 
on  the  outer  aspect  of  the  elbow- joint,  replacing  the  normal  depression 
between  the  olecranon  and  the  e.xternal  condyle: 


DISEASES    OF   THE    INDIVIDUAL    JOIXTS. 


^33 


i.  e.,  limitation  of  its  normal  movements;  ih)  whether  any  swelhng  is 
present;  (c)  whether  tapping  upon  the  trochanter  or  knee  causes  pain. 

4.  Measurement.  To  determine  the  presence  of  muscular  atrophy 
and  of  shortening. 

5.  X-ray  examination. 

1.  History. — This  should  include  not  only  the  mode  of  onset,  but 
also  whether  there  is  any  tuberculosis  in  the  family,  or  evidences  of 
recent  or  old  foci  elsewhere  in  the  patient.  The  usual  history  of  the 
mode  of  onset  is  that  it  has  been  gradual. 

In  but  few  cases  does  the  disease  begin  suddenly.  There  is  not 
infrequently  the  his- 
tory of  a  fall  upon  the 
trochanter  or  of  other 
injury  to  the  limb. 
The  first  symptom 
noticed  by  the  parents 
is  that  the  child  be- 
gins to  hmp,  and  the 
hip  is  held  a  httle  rigid. 
In  addition  the  child 
complains  of  pain  in 
the  hip  or  in  the  knee, 
which  is  increased  by 
any  movement  of  the 
affected  limb.  Often 
these  pains  are  in- 
creased at  night,  so 
that  the  child  awakens 
from    a    sound    sleep 

with  an  outcry  of  sudden  pain.  Intelhgent  parents  will  often  give  such 
a  history  of  gradually  increasing  lameness,  stiffness  of  the  hip,  and 
pain  that  the  attention  of  the  surgeon  is  at  once  attracted  to  this  joint. 

2.  Inspection  of  the  Limb. — This  will  give  much  information, 
and  the  child  should  be  thus,  examined,  if  possible  while  standing, 
walking,  and  lying  down,  being  stripped  of  all  suiJcrfluous  clothing. 
The  child  is  seen  to  limp,  resting  as  httle  weight  as  possible  upon  the 
toes  of  the  diseased  hmb.  The  pelvis  is  elevated  upon  this  side,  so 
that  the  limb  appears  shortened.  When  the  two  anterior  superior 
spines  are  outhncd  on  the  skin,  this  compensatory  tilting  of  the  pelvis 
can  be  well  seen.  Inspection  will  further  reveal  any  changes  in  the 
attitude  of  the  limb.     This  is  a  very  common  and  prominent  symptom, 


Fig.  430. — Appearance  of  Hands  in  Acute  Rheumatic  Polyartic- 
ular Arthritis. 


634 


THE   EXTREMITIES. 


and  is  due  to  the  reflex  muscular  spasm.  It  is  inadvisable  to  divide 
tuberculous  coxitis  into  three  stages  according  to  the  position  of  the  limb, 
for  the  reason  that  these  are  so  inconstant  as  to  lead  to  much  con- 
fusion. This  is  especially  true  of  the  early  stage.  In  the  early  period 
the  limb  is  usually  abducted  and  rotated  outward,  but  not  always 
flexed.  In  the  later  stages  the  attitude  of  the  limb  is  far  more  uni- 
form. At  such  time  there  is  marked  adduction,  internal  rotation, 
and  flexion.     The  limb  in  the  early  stages  appears  to  be  shortened,  but,  as 


Fig.  431. — Various  Positions   in  Hip-joint  Disease  (Edmund  Owen). 
I,  Compensatory  lordosis  in  hip-joint  disease;  2,  method  of  estimating  degree  of  flexion  of  the  hip,  when 
back  touches  table;    3,  amount  of  fixation  of  hip-joint.     The  normal  left  hmb  can  be  flexed  upon  the  ab- 
domen;   the  diseased  limb  forms  the  angle  shown  in  the  figure. 


has  just  been  explained,  this  is  the  result  of  tilting  of  the  pelvis.  In 
the  later  stages  the  shortening  of  the  limb  is  genuine,  due  to  actual 
loss  of  bone  substance. 

Abduction  of  the  hmb  causes  the  pelvis  to  be  raised,  while  adduction 
results  in  its  being  lowered.  The  flexion  of  the  joint  causes  a  com- 
pensatory lordosis,  and  the  degree  of  flexion  can  be  readily  estimated. 

3.  Palpation  for  Limitation  of  Motion,  Location  of  Pain, 
and  Swelling. — Palpation  yields  much  information  of  diagnostic  value. 


DISEASES    OF   THE    INDIVIDUAL    JOINTS.  635 

The  child  should  be  laid  upon  a  firm  couch  or  table  and  the  range 
of  motion  upon  the  healthy  side  first  ascertained,  as  this  will  often 
clear  up  the  question  as  to  whether  any  rigidity  is  due  to  the  child 
being  frightened. 

The  suspected  limb  should  be  held  at  the  knee  with  one  hand  while 
the  other  grasps  the  pelvis. close  to  the  hip  (Fig.  327).  The  examina- 
tion should  determine  whether  there  is  any  hmitation  of  abduction 
or  adduction  of  the  limb.  When  this  movement  is  limited,  the  pelvis 
moves   with    the   diseased    limb.     The    des^ree    of   flexion   can    either 


Fig.  432. — Method  of  Tapping  Knee  to  Determine  Tenderness  in  Cases  of  Suspected  Hip-joint 

Disease. 

The  patient's  knee-joint  region  is  allowed  to  rest  upon  the  surgeon's  left  or  right  hand,  as  the  case  may  be, 

while  the  opposite  hand  taps  upon  the  region  of  the  patella. 

be  determined  while  the  patient  is  lying  upon  the  back  (Fig.  430)  or 
upon  the  abdomen.  Under  normal  conditions  a  child  lying  upon  its 
back  shows  only  a  slight  amount  of  lordosis  of  the  lumbar  portion 
of  the  spinal  column  (Fig.  432)  when  the  hmb  is  fully  extended. 
In  hip-joint  disease  a  marked  lordosis  will  appear  (Fig.  430)  when 
attempts  are  made  to  extend  the  limb.  The  degree  of  flexion  can  be 
roughly  determined  by  allowing  the  lumbar  spine  (Fig.  432)  to  touch 
the  table.  Such  a  test  cannot  be  used  where  much  pain  exists.  If 
the  patient  lies  upon  the  abdomen  the  amount  of  flexion  can  be  de- 


636 


THE    EXTREillTIES. 


termined  by  placing  the  hand  upon  the  sacrum  and  alternately  raising 
the  affected  and  the  normal  hmb.  In  case  there  is  limitation  of  inward 
and  outward  rotation,  the  thigh  is  flexed  to  a  right  angle  while  one  hand 
grasps  the  knee.  Efforts  are  then  made  to  turn  the  femur  outward 
and  inward.  In  the  early  stage  of  hip-joint  disease,  the  motions  which 
are  Hmited  are  abduction,  h}'perextension,  and  rotation.  In  the  later 
stage,  the  motions  are  limited  in  all  directions. 

Location  of  Pain. — Palpation  is  also  utilized  to  determine  the  pres- 
ence of  pain  and  of  swelhng.  Referred  pain,  however,  mav  not  be 
present  at  any  stage  of  the  disease,  and  is  not  nearly  so  valuable  a 
diagnostic  sign  as  the  others  mentioned  here.  When  present,  pain  is 
usually  felt  on  the  inner  side  of  the  thigh,  close  to  the  knee-joint.     Pain 


Fig.  433. — XoRMAL  Degree  of  Lordosis  of  Speve. 
Note  the  slight  forward  curvature  in  lumbar  region  of  a  child  King  in  normal  supine  jxjsition. 


in  the  joint  itself  is  less  constant.  There  is  often  sensitiveness  to  pres- 
sure over  the  trochanter  and  when  the  knee  is  gently  tapped  (Fig.  431). 
Pain  is  also  quite  marked  upon  pressing  deeply  over  the  front  and  back 
of  the  joint. 

SweUing. — There  is  often  a  distinct  thickening  to  be  felt  over  the 
head  of  the  femur  at  Scarpa's  triangle  or  behind  the  trochanter.  This 
sign  is  ver}-  difhcult  to  elicit,  especially  in  the  more  acute  cases.  There 
is  at  times  enlargement  of  the  inguinal  glands  below  Poupart's  ligament. 
Abscesses  usually  appear  over  the  front  of  the  joint,  but  may  gravitate 
toward  the  trochanter  or  downward  toward  the  knee.  Similarly,  sin- 
uses may  be  present  at  any  point. 

4.  Measurements  of  the  Limb  for  Shortening  and  Atrophy. — 
The  apparent  shortening  referred  to,  as  existing  in  the  early  stages  can 


DISEASES    OF    THE    INDIVIDUAL    JOINTS. 


637 


be  ascertained  by  the  methods  of  measurement  of  the  hmb  as  described 
on  page  493.  Later  in  the  disease,  this  same  measurement  reveals 
an  actual  shortening,  var}'ing  according  to  the  amount  of  destruction 
of  the  head  and  neck. 

The  presence  of  atrophy  even  at  an  early  stage  is  a  diagnostic  sign 
of  considerable  value  in  this  disease.  The  degree  of  muscular  atrophy 
is  ascertained  by  measuring  the  circumference  of  both  hmbs  at  the 
middle  of  the  thighs  (Fig.  434)  and  middle  of  the  legs  (Fig.  435). 

In  the  later  stages  a  rectal  examination  should  never  be  omitted, 
for  evidences  of  perforation  of  the  acetabulum,  with  resultant  intra- 
pelvic  inflammatory  induration  and  abscess  formation. 

5.  X-ray    Examination. — As    was    stated    in    the    consideration 


Fig.  434. — Method  of  Determining  the  Circumference  of  the  Thigh  at  its  Middle.     (See  te.xt.) 


of  the  diagnosis  of  joint  diseases  in  general,  this  mode  of  examination 
can  only  be  utilized  at  such  a  late  period  in  tuberculous  arthritis,  that 
a  diagnosis  is  possible  in  the  majority  of  cases  without  it.  This  is 
especially  true  of  the  hip-joint,  where  the  destruction  of  bone  must 
be  fairly  extensive  before  it  will  show  in  a  skiagraph. 

DiJfferential  Diagnosis.-^i.  PoWs  Disease  {Tuberculous  Spon- 
dylitis).— A  tuberculous  lumbar  spondylitis  may  greatly  resemble  hip- 
joint  disease,  owing  to  the  hmb  being  held  in  a  rigidly  flexed  position. 
There  is,  however,  no  limitation  of  the  motions  of  rotation,  abduction, 
or  adduction  of  the  hip.  When  attempts  are  made  to  extend  the  hip 
no  compensatory  lordosis  appears,  the  spine  being  held  rigid.  This 
latter   symptom   of  spondyhtis  is  more   distinctly  brought    out    when 


638 


THE    EXTREMITIES. 


the  child  is  asked  to  sit  up,  after  lying  upon  the  back.  It  will  employ 
every  effort  to  raise  and  support  itself  by  the  use  of  the  hands,  in  order 
to  keep  the  infiamed  lumbar  spine  rigid.  The  pains  are  referred  to 
the  spine  or  along  the  lower  abdominal  nerves,  and  are  usually  sym- 
metrical. 

2.  Chronic  Arthritis  Deformans  {Morbus  Coxoe  Senilis). — This 
might  come  into  question  in  elderly  patients  more  often  than  in  children, 
in  whom  it  is  infrequent.  There  is  marked  crepitation  when  the  hip  is 
rotated.  The  movements  are  only  slightly  limited.  The  x-ray  would 
show  bony  hypertrophy. 

3.  Acute  Osteomyelitis  of  the  Upper  End  of  the  Femur. — The  pain 
is  far  more  acute  than  in  tuberculous  coxitis,  there  is  high  fever,  and 


Fir..  435,- — Method  of  Measuring  the  Circumference  of  the  Lower  Limb  at  the  Level  of  the  Mid- 
dle OF  THE  Calf.     (See  text.) 


much  swelling  about  the  hip.  There  are  other  signs  of  general  infec- 
tion, such  as  a  rapid  pulse,  leukocytosis,  and  often  delirium.  The  de- 
struction of  the  bone  is  rapid,  and  abscess  formation  and  shortening 
occur  at  an  early  period. 

4.  Rheumatic  and  Other  Forms  of  Primary  and  Secondary  Arthri- 
tis.— In  these  the  history  of  the  previous  infection  is  of  the  utmost  impor- 
tance, since  the  symptoms  greatly  resemble  those  of  tuberculous  cox- 
itis. They  can  be  distinguished  from  the  latter  only  by  their  shorter 
course  and  the  previous  history. 

5.  Coxa  Vara. — The  differential  diagnosis  of  this  affection  is  con- 
sidered on  page  647. 

6.  Neoplasms  of  the  Head  of  the  Femur. — Both  carcinoma  and 
sarcoma  of  distant  organs   may  be  followed   by  metastatic  deposits 


DISEASES    OF   THE    KNEE-JOINT. 


639 


in  the  head  of  the  femur  and  simulate  tuberculous  coxitis,  on  account 
of  the  pain,  rigidity,  swelhng,  and  shortening.  In  the  case  shown 
in  Fig.  409  there  was  also  evening  rise  of  temperature.  The  diagnosis 
rests  upon  an  accurate  previous  history,  the  examination  of  the  remainder 
of  the  body  for  primary  growths,  and  the  x-ray. 

7.  Inflammation  of  the  Iliopsoas  Bursa. — This  may  also  cause  abduc- 
tion, outward  rotation,  and  flexion  of  the  thigh,  as  well  as  pain  radiat- 
ing to  the  knee,  x^dduction  and  inward  rotation  are  impossible  with- 
out an  anesthetic,  while  abduction  and  outward  rotation  are  free.     The 


SPB 


PPB 


Fig.  436. — Location  of  Various  Collections  or  Fluid  in  the  Vicinity  of  the  Knee-joint 
^4,  Effusion  into  the  Icnee- joint,  and  suprapatellar  bursa:  i^,  Femur;   T,  tibia;  5PB,  suprapatellar  bursa; 
PPB,  location  of  prepatellar  bursa;    IPB,  intrapatellar  bursa.     B,  This  illustration  shows  the  simultaneous 
collection  of  fluid  in  the  prepatellar  bursa  (PPB),  and  within  the  knee-joint  itself. 


swelling  over  the  joint  is  more  marked  than  in  coxitis,  and  deep  fluc- 
tuation can  often  be  obtained. 

Abscesses  of  this  bursa  may  rupture  into  the  hip-joint  and  vice 
versa. 


DISEASES  OF  THE  KNEE-JOINT. 

No  joint  of  the  body  is  more  frequently  the  seat  of  the  various 
forms  of  acute  and  chronic  arthritis  than  the  knee.  It  will  be  unneces- 
sary to  repeat  the  chief  diagnostic  points  of  these  affections,  since  in 
every  case  one  must  make  the  diagnosis  by  the  process  of  exclusion 
outhncd  in  the  discussion  of  joint  diseases  in  general.  The  local 
signs  vary  accorch'ng  to  tlie  nature  of  tlie  ])rocess,  /.  c,  whether  it  be 


640 


THE    EXTREMITIES. 


acute  or  chronic,  and  again  whether  the  effusion   be  serous,   seropu- 
rulent,  hemorrhagic,  or  purulent. 

The  following  signs  are  common  to  the  majority  of  the  acute  and 
chronic  processes: 

1.  Pain  in  the  knee  and  tenderness  on  pressure,  especially  along 
the  lines  of  reduphcation  of  the  capsule. 

2.  Obliteration  of  the  depressions  on  all  sides  of  the  patella.     This 

may  either  be  due  to  the 
presence  of  fluid  in  the 
joint  itself  or  in  the  sub- 
crural  bursa,  or  it  may  be 
the  result  of  thickening  of 
the  capsule  or  of  a  peri- 
articular infiltration. 

3.  Ballottement  of  the 
patella.  This  is  to  be 
found  if  only  a  small 
quantity  of  fluid  be  pres- 
ent. It  is  elicited  either 
by  tapping  hghtly  on  the 
patella  or  by  placing  the 
index-fingers  upon  it  and 
exerting  pressure.  With 
either  method  the  patella 
springs  back  again  when 
the  pressure  is  relieved. 
Fluid  in  the  prepatellar 
bursa  causes  fluctuation 
in  front  of  the  patella,  and 
the  latter  cannot  be  made 
to  dance  upon  the  fluid  as 
is  the  case  with  an  intra- 
articular effusion.  In  ad- 
dition to  this  sign,  the  prominence  is  only  over  the  patella,  and  there  is 
but  little,  if  any,  obliteration  of  the  normal  depressions  around  the 
patella  (Fig.  439). 

4.  The  position  or  attitude  of  the  hmb.  The  knee  in  the  more 
acute  cases  is  held  rigidly  extended  at  first,  but  gradually  flexion  takes 
place.  As  the  cartilages  become  eroded  and  the  ligaments  relaxed 
various  deformities  occur.     These  may  be   (a)   extreme  flexion;    (b) 


Fig.  437. — Side  View  of  Knee-joint  in  a  Case  of  Acute 
Synovitis. 
The  arrows  point  to  the  spaces  above  and  below  the  patella, 
which  are  depressions  in  the  normal  knee-joint,  becoming  ob- 
literated and  bulging  as  soon  as  fluid  collects  in  the  knee-joint. 


DISEASES    OF    THE    KNEE-JOINT. 


641 


subluxation  of  the  tibia  (Fig.  417);   (c)  genu  valgum  or  genu  varum,  or 
even  genu  recurvatum,  i.  e.,  backward  curvature  or  hyperextension. 

5.  Manipulation  of  the  limb  may  reveal  crepitus,  either  due  to 
adhesions  or  fibrinous  deposits  or  to  erosion  of  cartilage.  It  may  also 
show  relaxation  of  the  hgaments  (Fig.  335)  or  enlargement  of  the  arti- 
cular ends  of  the  bones. 

6.  In  the  acute  and  chronic  suppurative  processes,  sinuses  may 
form  on  all  sides  of  the  joint  and  lead  by  a  tortuous  route  to  the  inside 
of  the  capsule. 

The  most  frequent  form  of  inflammation  of  the  knee-joint  or  gonitis 


Fig.  438. — Method  of  Determining  the  Presence  of  Fluid  in  the  Knee-joint,  by  Ballottement 
OR  Dancing  of  the  Patella  on  the  Underlying  Fluid. 
Two  fingers  are  placed  at  the  upper  level  of  the  patella  and  two  at  the  lower,  and  alternately  pressure 
is  made.     The  patella  can  then  be  felt  to  be  pushed  back  and  forward,  springing  back,  as  it  were,  like  a  solid 
body  when  itis  pressed  upon  while  lying  in  water. 

is  the  tuberculous,  and  brief  reference  must  be  made  to  its  chief  diag- 
nostic features. 

Tuberculosis  of  the  Knee-joint  (Tuberculous  Gonitis). — This 
may  occur  in  those  who  are  enjoying  apparently  the  best  of  health,  as  well 
as  in  those  who  have  marked  evidence  of  tuberculosis  elsewhere.  Some 
cases  apparently  follow  a  trauma.  In  the  majority  of  cases,  however, 
such  an  injury  is  a  very  remote  one,  and  has  little  lo  do  with  the  devel- 
opment of  the  process.  The  more  important  symptoms  of  diagnostic 
value  are  swelling  of  the  joint,  tenderness  on  pressure,  pain,  fixation, 
atrophy,  local  heat,  and,  later  in  the  disease,  deformities. 
41 


642 


THE    EXTREMITIES. 


I.  Swelling. — This  is  usually  most  marked  on  either  side  of  the 
patella.  When  muscular  atrophy  of  the  thigh  and  leg  takes  place 
the  limb  assumes  a  typical  spindle  shape  (Fig.  438).  The  swelhng 
has  a  semifluctuating  or  elastic  consistency,  due  to  the  granulations 
■within  the  joint  and  to  the  iniilttation  of  the  capsule  and  periarticu- 
lar tissues.  It  is  the  action  of  the  latter  upon  the  overlving  skin,  caus- 
ing it  to  be  glazed  and  anemic,  which  gave  this  form  of  tuberculosis  the 
old  term  of  "tumor  albus." 

If  the  joint  contain  either  a  serous  or  purulent  effusion  as  the  result 

of  the  tuberculous  process,  there  is 
more  distinct  fluctuation,  the  space 
above  the  patella  is  filled  out,  and 
the  patella  itself  shows  the  phenom- 
enon of  ballottement.  If  such  a 
joint  eilusion  recurs  from  time  to 
time  and  explorator}^  puncture  shows 
it  to  consist  of  fibrin  or  to  contain 
rice  bodies  it  should  be  regarded  as 
strongly  suspicious  of  tuberculosis. 
In  some  cases  the  diagnosis  may 
be  made  if  a  palpable  thickening  of 
the  capsule  remains  after  the  fluid 
has  disappeared. 

2.  Pain,  Tenderness,  and  Local 
Heat. — There  is  but  little  pain,  ex- 
cept in  the  more  acute  cases,  and  the 
same  is  true  of  local  heat.  Tender- 
ness is  present  especially  over  the 
upper  end  of  the  tibia.  The  more 
acute  the  process,  the  more  marked 
are  the  local  pain,  heat,  and  tender- 
ness. 

3.  Rigidity,  Atrophy,  and  De- 
formity.— The  patient  walks  with  a  decided  limp,  the  knee  being  held 
rigid.  The  muscular  fixation  is  not  so  great  as  in  the  hip-joint,  and 
many  cases  permit  of  quite  free  manipulation.  ^Muscular  atrophy 
appears  early  and  is  usually  quite  marked.  The  position  is  at 
first  that  of  mild  flexion,  the  leg  being  rotated  slightly  outward. 
As  the  process  advances  the  flexion  deformity  becomes  more  marked 
and  may  be  accompanied  by  subluxation  of  the  tibia,  the  latter  lying 
in  a  plane  behind  that  of  the  femur  (Fig.  418).     An  enlargement  of 


Fig.  439. — ^Anterior  View  of  a  Case  of  Ad- 
vanced TUBERCIILOSIS   OF  THE   KnEE-JOINT 

(Left). 

Observe  how  the  depressions  normally  exist- 
ing on  all  sides  of  the  patella  have  been  obliter- 
ated, especially  that  above  the  pafella  correspond- 
ing to  the  seat  of  the  suprapatellar  bursa. 


DISEASES    or   THE    KNEE-JOINT. 


643 


the  lower  end  of  the  femur  and  a  genu  valgum  position  is  also  frequently 
found  in  advanced  cases. 

4.  Abscess,  Sinus  Formation,  and  Fever. — As  a  rule,  there  is  only 
a  slight  rise  of  the  evening  temperature,  99°  to  100°  F.,  but  in  some 
cases,  the  formation  of  pus  not  only  manifests  itself  by  an  increase  in 
severity  of  the  local  symptoms,  but  also  by  a  considerable  rise  in  the 
general  temperature,  at  times  to  103°.  In  such  cases  one  often  ques- 
tions the  possibility  of  the  process  being  of  a  tuberculous  nature  with- 
out the  history  of  its  gradual  onset,  the  presence  of  the  disease  else- 
where in  the  patient  himself  or 
in  his  family,  and  lastly  the 
fact  that  the  capsule  feels  much 
thicker  than  is  the  case  in  an 
ordinary  acute  arthritis. 

Abscess  formation  may  also 
occur  from  extraarticular  foci. 
These  are  usually  found  as  quite 
localized,  distinctly  fluctuating 
swelling  over  the  tibia  or  one 
of  the  condyles.  Sinuses  may 
be  present  on  all  sides  of  the 
joint. 

5.  X-ray  shows  erosions  of 
cartilage  and  foci  in  bones. 

Differential  Diagnosis. —  i. 
From  some  of  the  acute  forms  of 
arthritis.  The  resemblance  of 
some  cases  of  acute  pus  forma- 
tion in  tuberculous  knees  to  other 
forms  of  acute  arthritis  has  just 
been  referred  to.  Of  these  latter  there  are  some  which  require  special  men- 
tion, viz.,  acute  gonorrheal  or  gonitis,  the  acute  forms  of  hemophihac  gon- 
itis and  some  cases  of  monarticular  acute  rheumatism  (Fig.  442).  These 
can  only  be  differentiated  by  the  history  of  gradual  development  in  tuber- 
culosis, followed  by  acute  symptoms.  In  the  gonorrheal  form  the  history 
and  local  examination  of  the  urethra  will  clear  up  the  diagnosis.  In  the 
hemophiliac  arthritis  there  is  not  so  much  pain  or  tenderness  or  fever, 
and  exploratory  puncture  reveals  l)lood.  Tlic  history  will  also  be  of 
the  greatest  aid.  The  monarticular  rheumatic  arthritis  yields  readily 
to  appropriate  treatment  and  is  at  times  accompanied  by  a  purpuric 
skin  eruption  (Fig.  442). 


Fig.  440. — Lateral  View  of  Same  Patient  shown 

IN  Fig.  438. 

Illustrating   the  characteristic  flexion  deformity,  and 

the  prominence  of  the  suprapatellar  bursa;. 


644 


THE    EXTREMITIES. 


Both  in  children  and  aduhs  a  swelhng  of  the  knee-joint  may  persist 
for  a  long  time  after  an  injury.  It  may  disappear  and  then  recur  as 
described  on  page  614,  the  question  often  arising  as  to  whether  the 
process  is  a  tuberculous  one.  In  children,  effusions  which  persist  for  a 
considerable  period  after  an  injury,  must  be  looked  upon  with  suspicion. 
In  adults  such  a  chronic,  often  recurrent  effusion,  if  tuberculous,  is  apt 
to  be  accompanied  by  the  capsular  thickening  and  other  signs  just 
described. 

Other  conditions  which  must  be  considered  in  the  differential 
diagnosis  are  arthritis  deformans,  tabetic  arthropathy,  sarcoma  of  the 


Fig.  441. — Characteristic  Flexion  DEFORinTY  in  a  Child  Suffering  from  Teberculosis  of  the 

Right  Kivee-joint. 
Xote  the  swelling  above  and  below  the  patella,  and  the  absence  of  normal  depressions. 

femur  and  tibia,  hpomata  of  the  joint  and  hysterical  joints,  as  well 
as  diseases  of  the  periarticular  bursae  (page  566). 


DISEASES  OF  THE  ANKLE-JOINT. 

The  acute  forms  of  arthritis  require  no  special  mention,  the  most 
frequent  of  these  being  due  to  acute  rheumatism,  gonorrhea,  and  to 
trauma.  Of  the  chronic  forms  those  due  to  tuberculosis  and  tabes 
are  of  chief  interest.  The  tabetic  joints  occur  frequently  enough  in 
middle  hfe  to  lead  to  errors  in  diagnosis.  The  local  signs  of  the  disease, 
viz.,  enormous  enlargement  of  the  joint,  abnormal  mobility  in  all  direc- 
tions, without  pain  and  marked  crepitation,  combined  with  the  more 
general  evidences  of  tabes,  serve  to  make  the  diagnosis  comparatively  easy. 


DISEASES    OF    THE    ANKLE-JOINT. 


645 


Tuberculosis  of  the  Ankle-joint. — i.  Swelling.  As  in  all  effu- 
sions into  the  ankle  the  first  evidences  are  seen  by  a  fullness  of  the 
depressions  over  the  front  and  later  along  the  lateral  aspects  (below 
the  malleoli  and  behind  the  joint).  The  swelling  has  the  same  elas- 
tic consistency  as  in  diseases  of  the  knee-joint,  soon  giving  rise  to  the 
typical  spindle-like  shape,  through  atrophy  of  the  leg  muscles. 

2.  Gait  and  position  of  foot.  The  patient  walks  very  lame,  the 
foot  is  held  in  an  extended 

and  somewhat  adducted  posi- 
tion.   The  ankle  is  held  rigid. 

3.  Pain  and  tenderness. 
Pain  is  present  at  an  early 
stage  and  causes  marked 
lameness,  so  that  the  patient 
steps  very  lightly  on  the  dis- 
eased foot.  There  is  tender- 
ness on  pressure  over  the  en- 
tire joint.  Attempts  at  move- 
ment of  the  joint  and  pres- 
sure of  the  foot  against  the 
leg  cause  great  pain. 

Differential  Diagnosis. 
— The  principal  conditions 
from  which  tuberculosis  of 
the  ankle-joint  must  be  dif- 
ferentiated are  the  chronic 
forms  of  arthritis  of  this  joint 
following  injury  and  tuber- 
culosis of  the  tarsal  joints. 
In  the  chronic  traumatic  form 
there  is  an  absence  of  the 
peculiar  boggy  elastic  swell- 
ing, there  is  much  less  pain,  and  if  tenderness  is  present,  it  is  not  so 
diffuse. 

Tiihercidosis  0}  the  Tarsal  Joints  {Mcdio-tarsal  and  Tarso-tarsal).— 
In  many  cases  if  sinuses  are  present  and  the  foot  is  uniformly  swollen 
a  differentiation  is  impossible.  In  general,  however,  the  pain,  tender- 
ness and  swelling  are  in  the  anterior  and  middle  portions  of  the  foot 
and  over  the  particular  joint  in\olved,  wliilc  the  movements  of  the 
ankle-joint  proper  are  free  and  painless. 

In  primary  tuberculosis  of  the  os  calcis  there  is  swelhng  behind 


Fig.  442. — Purpura  Rheumatica  Associated  with  En- 

LARGEJIENT  OF  THE  LeFT  KnEE-JOINT  OF  A  RHEUMATIC 

Xature. 


646 


THE    EXTREMITIES. 


the  ankle-joint  only.     The  bone  itself  is  thickened  and  tender,  and, 
if  sinuses  are  present,  the  probe  encounters  rough  bone. 


DEFORMITIES. 

Congenital  Dislocations. 
Of  the  Hip. — This  occurs  most  often  in  female  children,  and  the 
attention  of  the  physician  or  surgeon  is  seldom  drawn  to  the  condition 

until  the  child  begins  to  walk. 
At  such  a  time  the  gait  of  the 
child  resembles  the  waddling 
mode  of  locomotion  of  a  duck. 
This  is  most  marked  if  the  af- 
fection is  a  bilateral  one.  If 
it  is  present  on  one  side  only, 
the  child  seems  to  suddenly 
sink  when  stepping  upon  the 
foot  of  the  affected  side.  This 
sudden  shortening  of  the  limb 
is  due  to  the  fact  that  the  head 
has  no  fixed  point,  as  is  the 
case  with  the  normal  head  in 
the  acetabulum.  It  slides  up 
on  the  ilium  when  the  child 
rests  its  weight  on  the  affected 
limb  and  causes  this  marked 
limping. 

The  most  important  diag- 
nostic signs  are: 

1.  A  waddhng  gait  in  bi- 
lateral, and  the  characteristic 
limp  or  sudden  shortening  in 
unilateral  dislocations. 

2.  The  trochanter  lies 
above  the  Roser-Nelaton  hne,  as  in  a  traumatic  dislocation,  but  it  can 
be  pulled  down  by  force. 

3.  The  limb  is  shortened,  as  compared  with  its  fellow,  in  unilateral 
dislocations.  This  varies  from  i  to  3  cm.  in  children  one  to  two  years 
of  age  to  8  cm.  in  older  ones. 

4.  On  deep  palpation  one  can  usually  feel  the  head  of  the  femur 
upon  the  dorsum  ihi.     This  is  best  done  when  the  child  hes  upon  its 


\ 


Fig.  443. — Double  Congenital  Dislocation  of  Hip 
(from  a  photograph  in  the  collection  of  Dr.  J.  E. 
Moore). 


DEFORMITIES. 


647 


back  and  the  limb  is  rotated  with  one  hand,  while  the  other  grasps 
the  head.  The  head  can  be  pulled  down  by  traction  upon  the  limb. 
5.  The  Trendelenburg  sign.  When  a  normal  child  stands  upon 
either  limb  and  flexes  the  other  at  the  knee  and  thigh,  the  opposite 
buttock  will  not  be  seen  to  drop.  In  the  child  with  congenital  dislo- 
cation, however,  the  opposite  healthy  buttock  will  be  seen  to  drop 
when  the  child  stands  upon  the  affected  limb  so  that  the  gluteal  fold  is 
at  a  lower  level.  This  is  due  to  the  fact  that  the  gluteal  muscles  upon 
the  dislocated  side  are  unable  to  perform  their  function  of  keeping  the 
pelvis  level. 


Fig.  444. — X-RAY  OF  Congenital  (Right-sided)  Dislocation  of  the  Femur  at  the  Hip-joint. 


6.  There  is  a  marked  lordosis  and  scoliosis  toward  the  affected 
side.     If  the  lesion  is  bilateral  the  lordosis  is  very  striking. 

7.  The  x-ray  examination  is  of  great  value,  especially  in  young 
infants  who  are  quite  fat,  the  head  and  trochanter  being  difficult  to 
palpate  (Fig.  444). 

Differential  Diagnosis.^Coxa  Vara  (see  page  648). — In  this 
affection  the  head  cannot  be  felt  in  an  abnormal  position.  It  resem- 
bles congenital  dislocation  in  the  fact  that  the  Hmb  is  shortened  and 
that  the  trochanter  lies  above  the  Roser-Nelaton  hne.  Coxa  vara  is 
seldom  observed  at  as  early  an  age  as  a  congenital  dislocation.  There 
is  also  an  absence  of  the  freedom  of  motion  seen  in  the  latter  affection. 
In  coxa  vara  there  is  marked  hmilation  of  a1)(luction  and  of  inward 


648  THE    EXTREMITIES. 

rotation.  In  case  of  any  doubt  a  skiagraph  will  clear  up  the  diag- 
nosis. 

Paralytic  Flail  Joint  {Paralytic  Dislocation). — In  this  condition 
there  is  also  displacement  of  the  head,  the  trochanter  lies  above  the 
Roser-Nelaton  hne,  and  there  is  lumbar  lordosis.  There  is  usually 
evidence  in  the  thigh  and  leg  of  extensive  paralysis,  and  atrophy  or 
shortening  (Fig.  450). 

Dislocation  Following  Arthritis  0}  the  Hip. — The  symptoms  of  the 
spontaneous  forms  of  dislocations  of  the  hip,  following  some  of  the 
infectious  diseases,  resemble  those  of  the  congenital  form  in  almost 
every  particular.  There  is,  however,  usually  a  history  of  the  primary 
affection,  and  the  fact  that  before  the  onset  of  the  latter,  the  patient 
was  able  to  walk  perfectly.  The  motions  of  the  hip  are  also  not  as 
free  as  in  the  congenital  form. 

Congenital  Dislocations  of  Other  Joints. — Congenital  dislocation 
of  the  knee  is  not  frequent,  only  ninety-eight  cases  having  been  reported. 
It  is  regarded  by  some  authors  as  a  genu  recurvatum  or  a  hyperextension, 
rather  than  a  displacement.  It  is,  however,  to  be  looked  upon  as  a  true 
dislocation,  and  is  frequently  double.^  The  leg  is  usually  displaced  for- 
ward, so  that  the  condyles  of  the  femur  project  in  the  popliteal  space. 

Congenital  Dislocation  of  the  Patella. — This  is  also  infre- 
quent. The  displacement  is  usually  outward,  as  in  one  of  the  varie- 
ties of  traumatic  dislocation.  In  this  connection  may  be  mentioned 
the  rare  occurrence  of  congenital  absence  of  the  patella,  which  can  be 
recognized  by  the  knee  being  broad  and  flat  and  very  much  impaired 
in  function. 

Congenital  Dislocation  of  the  Shoulder. — This  is  very  rare. 
In  the  majority  of  cases  reported  as  such  it  was  due  to  relaxation  of  the 
joint  (following  the  form  of  paralysis  described  on  page  437)  owing 
to  tearing  of  the  upper  roots  of  the  brachial  plexus  (Fig.  271).  In 
others  it  is  due  to  separation  of  the  epiphysis. 

Coxa  Vara. 

The  attention  of  the  profession  was  first,  called  to  this  interesting 
deformity  by  E.  Miiller  ^  in  1888,  and  the  name  coxa  vara  given  to  it 
by  Hofmeister  in  1894.  It  may  be  defined  as  a  bending  downward 
(Fig.  445)  of  the  neck  of  the  femur  sufficiently  to  cause  symptoms. 
The  neck  may  form  a  right,  or  even  an  acute,  angle  with  the  shaft. 

CHnically  it  is  seen  most  often  in  males  during  adolescence  and 
less  frecjuently  in  children. 

^  "Zeitschrift  fur  orthopedische  Chirurgie,"  vol.  vii. 


DEFORMITIES. 


649 


It  is  best  divided  into  the  following  forms : 

1.  Congenital  coxa  vara. 

2.  Rachitic  coxa  vara  of  childhood. 

3.  Coxa  vara  of  adolescence. 

4.  Traflmatic  coxa  vara. 

5.  Inflammatory  and  trophic   coxa  vara   (following  osteomyelitis, 
arthritis    deformans,    osteitis    deformans,    osteomalacia).     The    symp- 


Fig.  445- — X-RAY  OF  A  Case  of   Coxa  Vara,  Taken  from  the  Patient  shown  in  Figs.  446  and  447. 
Note  the  downward  inclination  of  the  neck  of  the  femur  on  the  side  of  the  coxa  vara  (right),  and  the  mush- 
room-hke  expansion  of  the  head  of  the  bone.     On  the  left  side  the  epiphj'seal  line  between  the  head  and  the 
neck  and  between  the  greater  trochanter  and  shaft  respectively  are  well  shown. 


toms  of  all  of  these  forms  are  the  same,  the  division  beinc  according: 
to  the  age  at  which  it  is  first  observed,  and  the  etiology. 

The  form  which  requires  especial  mention  in  connection  with  its 
etiology  is  the  traumatic.  This  term  was  first  given  to  it  by  Sprengel 
in  1898.^ 

It  follows  either  a  separation  of  the  ci)iphysis  or  an  actual  fracture 
of  the  neck  of  the  femur  in  cliildren  and  young  adults.  In  the  case 
of   epiphyseal   separation,    as    well   as   of   fracture   of    the    neck,   the 

'  "Archiv  fijr  klinische  Chirurgic,"  vol.  Ivii. 


6;o 


THE   EXTREMITIES. 


head  of  the  bone  becomes  flattened  or  mushroom-hke  and  the  neck 
bent  downward  so  as  to  he  below  the  level  of  the  trochanter.  The 
injury   may   be    so    slight    as    to    be    overlooked,    until   the   resulting 

deformity  appears.  Reference  has  been 
made  to  the  symptoms  of  fracture  of 
the  femoral  neck  in  children  (page  499) 
which  may  result,  according  to  Whitman,^  in 
coxa  vara.  The  diagnosis  of  coxa  vara  of 
whatever  origin  depends  upon  the  follo-^ing 
chnical  findings : 

1.  The  History. — The  early  symptoms 
depend  upon  the  cause.  In  those  due  to  trau- 
ma there  may  have  been  a  slight  or  severe 
injury,  followed  by  vague  pains  in  the  hip, 
and  later  the  appearance  of  the  deformity. 
In  others  there  is  a  histor}',  in  adolescence, 
of  gradually  increasing  pains  in  the  hip  and 
discomfort  on  walking. 

2.  Tlie  Symptoms  oj  the  Deformity. — 
[a)  Limitation  oj  Motion. — This  is  most 
marked  in  the  direction  of  abduction  and  in- 
Avard  rotation,  both  of  which  are  greatly  re- 
stricted. The  limitation  of  abduction  is  due 
to  the  pressure  of  the  trochanter  against  the 
ilium,  when  the  limb  is  abducted.  The  Kmi- 
tation  of  inward  rotation  is  due  to  the  fact 
that  the  neck  of  the  femur  is  not  only  bent 
downward,  but  also  backward  in  the  major- 
ity of  cases. 

(h)  Attitude  oj  tlie  Limb. — The  hmb  is 
everted  and  adducted,  except  when  the  neck 
is  bent  forward.  Under  the  latter  conditions 
it  is  inverted. 

(c)  Shortening.— This  is  one  of  the  most 
characteristic  signs.     There  is  genuine  short- 
ening as  measured  in  the  usual  manner  (Fig. 
447).     The  trochanter  lies  above  and  a  httle 
behind  the  Roser-Xelaton  line  (Fig.  447),  and  is  more  prominent  upon  the 
side  of  the  deformity.     In  children  the  shortening  may  be  slight.    There 
is  also  marked  atrophy  of  the  muscles  of  the  thigh  and  gluteal  region. 

^  "Annals  of  Surgery,"  1900. 


Fig.  446. — Typical   Position   in  a 
Case  of  Coxa  Vara  Adoles- 

CENTIUM. 

This  is  the  anterior  view  of  the 
case  shown  in  Figs.  445  and  447.  A, 
A,  Location  of  anterior  superior  spines 
of  the  ilium;  B,  B,  the  black  point 
above  these  letters  indicates  the  mid- 
dle of  the  patellae;  C,  C  lower  borders 
of  internal  malleoli.  Note  the  short- 
ening of  the  hmb,  the  external  rota- 
tion or  eversion,  and  the  prominence 
of  the  left  trochanter. 


DEFORMITIES. 


651 


(d)  Gait  and  Pain. — The  patient  stands  upon  the  toes  of  the  dis- 
eased side,  the  hmb  being  adducted  and  rotated  outward.  He 
limps,  and  if  the  affection  is  bilateral  there  is  a  distinct  waddhng 
gait.  There  is  also  more  or  less  pain  in  the  hip,  rarely  in  the  knee, 
when  walking.  The  Trendelenburg 
sign  is  also  well  marked  in  unilateral 
cases. 

3.  X-ray  Examination.  —  This 
shows  the  extent  of  the  deformity.  The 
bend  is  most  frequently  downward  and 
backward,  less  often  downward  and 
forward,  and  least  often  simply  down- 
ward. The  mushroom-like  flattening 
of  the  head  is  also  well  seen. 

Differential  Diagnosis/ — It  is  al- 
most impossible  to  differentiate  cases 
of  traumatic  coxa  vara  from  those  of 
true  coxa  vara  of  adolescence  except 
from  the  history.  If  the  trauma  has 
been  slight,  even  this  may  be  mislead- 
ing. 

From  Tuberculous  Coxitis. — Coxa 
vara  never  gives  rise  to  abscess  forma- 
tion, while  this  is  of  frequent  occur- 
rence in  tuberculous  coxitis.  The  on- 
set of  coxa  vara  is  more  abrupt  and 
acute  than  it  is  in  the  majority  of  cases 
of  tuberculosis  of  the  hip-joint.  It  is 
a  self-limited  disease,  and  sooner  or 
later  a-  spontaneous  cessation  of  the 
acute  symptoms  may  be  confidently  ex- 
pected, while  the  opposite  clinical  ten- 
dencies characterize  tuberculous  cox- 
itis. This,  like  tuberculous  processes 
in  other  parts  and  organs  of  the  body, 
is  generally  attended  by  a  slight  rise 
in  the  evening  temperature,  while  the 

temperature  in  coxa  vara  remains  normal.     In  the  great  majority  of 
cases,  tuberculous  coxitis  is  a  disease  of  cliildliood,  and  begins,  in  the  large 

'The  author  has  taken  many  of  the   differential  diagnostic  points  from  the  article 
of  Dr.  Nicholas  Senn. 


Fig.  447. — Posterior  View  of  a  Case  of 
Coxa  Vara  Adolescentium. 
Same  case  as  shown  in  Figs.  445  and  446. 
T,  The  arrow  points  to  the  prominent  tro- 
chanter on  the  side  upon  which  the  coxa  vara 
was  situated;  R,  R,  Roser-Xelaton  .Une. 
Note  how  the  trochanter  Hes  above  the  Roser- 
Nelaton  line  on  the  side  of  the  coxa  vara. 
Also  note  the  shortening  and  aversion  of  the 
limb. 


6S2 


THE    EXTREMITIES. 


proportion  of  instances  as  a  primary  osteal  affection  in  the  proximal  end 
of  the  femur.  Its  onset  is  insidious.  The  pain  is  referred  to  the  injflamed 
joint,  and  radiates  along  the  course  of  the  obturator  nerve  to  the  inner 
condyle  of  the  femur.  During  the  early  stage  of  the  disease,  the  thigh 
is  slightly  flexed,  abducted,  and  rotated  outward.  Nocturnal  muscu- 
lar twitching  is  almost  a  constant  symptom;  this  is  something  which 
is  never  found  in  coxa  vara.     In  tuberculous  coxitis,  muscular  rigidity 

fixes  the  joint  at  an  early  stage.  All 
movements  are  productive  of  pain,  and 
light  blows  against  the  condyles  invari- 
ably aggravate  the  pain.  Tenderness, 
such  a  marked  clinical  feature  in  tuber- 
culous and  other  inflammatory  affections 
of  the  hip-joint,  is  never  found  in  coxa 
vara.  Shortening  and  outward  rotation 
of  the  limb  belong  to  the  later  stages  of 
tuberculous  coxitis,  while  in  coxa  vara 
they  may  even  precede  the  painful  or 
acute  stage  of  the  disease,  and  the 
shortening  is  always  one  of  its  early 
manifestations,  usually  combined  with 
outward,  and,  in  exceptional  cases,  with 
inward  rotation  of  the  hmb.  As  a  final 
diagnostic  test  in  doubtful  cases,  the 
employment  of  the  Rontgen  ray  will  en- 
able us  to  differentiate  between  the  two 
affections  (Fig.  444).  In  coxa  vara,  the 
downward  bending  of  the  femoral  neck 
is  almost  characteristic,  while  in  tuber- 
culous coxitis  the  :r-ray  picture  will  either 
show  the  existence  of  a  destructive  pro- 
cess involving  the  proximal  end  of  the 
femur,  frequently  complicated  by  coexist- 
ing or  consecutive  disease  of  the  acetabulum,  or  it  will  show  no  change 
in  the  angle  of  the  neck. 

Bilateral  coxa  vara  is  of  more  frequent  occurrence  than  bilateral 
tuberculosis,  in  the  relative  proportion  with  which  these  two  diseases 
are  encountered  in  practice.  Muscular  atrophy  is  more  marked  in 
tuberculous  coxitis  than  in  coxa  vara. 

Arthritis  Deformans. — The  differential  diagnosis  between  coxa 
vara  and  arthritis  deformans,  called  senile  coxitis,  where  it  affects  the 


Fig.  448.- 


-Double  Genu  Valgum  (Fow- 
ler). 


DEFORMITIES. 


653 


hip-joint,   presents  fewer  difficulties.     Coxitis   senilis  is  a  disease  of 
advanced  life. 

Cases  of  senile  coxitis  are  seldom  met  with  in  persons  less  than  forty- 
five  years  of  age. 

In  senile  coxitis,  the  angle  of  the  neck  of  the  femur  is  not  diminished. 
Arthritis  deformans  is  not  infrequently  a  polyarticular  disease,  while 
coxa  vara  is  an  affection  which  is  only  met  with  in  the  hip-joint.  In 
senile  coxitis,  the  head  of  the  femur  occasionally  becomes  elongated, 
but  during  the  later  stages  the  upper  surface  is  deprived  of  its  carti- 
laginous covering,  and  the  exposed  underlying  bone  becomes  hardened 
and  is  pohshed  by  the  limited 
movements  of  the  joint.  There 
is  no  pain,  no  cracking,  or  rough- 
ness ehcited  by  joint  motion  as 
in  well-advanced  cases  of  senile 
coxitis.  The  shortening  of  the 
limb  in  senile  coxitis  is  not 
caused  by  bending  downward 
of  the  neck  of  the  femur,  but 
by  loss  of  tissue  of  the  head  of 
the  femur  and  the  upper  seg- 
ment of  the  acetabulum. 

Genu  Valgum  (Knock-knee). 
This  may  occur  as  a  symp- 
tom of  general  rachitis  in  early 
life  when  the  children  first  learn 
to  walk  (page  590).  It  also  ap- 
pears during  adolescence  (/.  e., 
between  the  twelfth  and  eight- 
eenth years)  as  a  static  de- 
formity. Genu  valgum  may  also  follow  fractures  of  the  femur  and 
paralysis  of  the  leg  and  thigh  muscles. 

The  diagnosis  in  these  varieties  is  not  difficult.     The  chief  features 
are: 

1.  An  inward  angular  deformity  (Fig.  448)  at  the  knee-joint,  which 
disappears  when  the  leg  is  flexed  upon  the  thigh. 

2.  When  the  leg  is  thus  flexed  the  internal  condyle  is  seen  to  be 
relatix'cly  prominent. 

3.  The  gait  is  quite  characteristic.     It  is  a  rolling  one,  the  leg  lacing 
thrown  outward  with  each  step  forwartl. 


Fig.  449. — Bow-legs  (Moore). 


654 


THE    EXTREMITIES. 


The  differentiation  of  either  genu  varum  rachiticum  or  adoles- 
centium  from  the  paralytic  or  traumatic  forms  presents  no  difficulty. 
The  presence  of  atrophied  and  paralyzed  muscles  will  ehminate  the 
paralytic  form  (Fig.  448),  and  the  histon,'  of  an  injury  will  exclude 
the  form  following  fractures  of  the  femur  or  tibia  or  laceration  of  the 
internal  lateral  ligament  of  the  knee. 


Genu  Varum  (Bow-legs). 
In  this  deformity  the  femur  and  tibia  form  an  outward  angle  (Fig. 
449).    Like  the  corresponding  inward  angular  deformity  (genu  valgum)  it 
is  most  frequently  the  result  of  rachitis,  and  is  one  of  the  earliest  evidences 

of  the  latter.  It  is  seen  even  in 
children  avIio  have  never  attempted 
to  stand.  In  later  life  a  similar 
deformity  appears  as  a  symptom 
of  osteitis  deformans  (page  592). 

The  distinctive  features  of  the 
rachitic  genu  varum  are:  (i)  The 
gait  is  a  waddling  one,  the  feet  and 
knees  being  wide  apart  and  the  toes 
usually  inverted;  (2)  the  deformity 
is  most  marked  in  the  femur  and 
tibia  when  one  is  in  the  standing 
position  (Fig.  449).  In  the  minor- 
itv  of  cases  the  bowing  is  either  an- 
gular  and  chiefly  in  the  lower  third 
of  the  tibia,  or  there  is  a  forward 
curving  of  the  tibia  and  sometimes 
of  the  femur  also.  To  the  latter 
class  the  term  anterior  bow-legs  is 
apphed. 

Deformities  Caused  by  Anterior 
Poliomyelitis. 

These  are  generally  of  three  var- 
ieties: {a)  Those  due  to  trophic 
changes,  resulting  in  atrophy  of  the 
bone  with  marked  shortening  of  the  hmb  (Fig.  450).  In  these  cases 
there  is  an  increased  liability  to  spontaneous  fracture.  (6)  Those  re- 
sulting from  muscular  paralysis.  These  either  cause  contractures  or 
flail  joints,     (c)  Dislocations,  either  complete  or  partial. 

The  first  class  are  not  difiicult  to  recognize,  the  only  other  causes 


Fig.  450. — Marked  Shortening  of  Right 
Lower  Extremity  Following  Anterior 
Poliomyelitis  in  Intancy. 

Note  the  pes  equinus  paralyticus  position  of  the 
foot. 


DEFORMITIES, 


655 


of  a  shortened  limb  being  a  fracture  through  the  epiphyseal  cartilage 
or  a  resection  of  the  ends  of  one  of  the  long  bones.  In  both,  the  history, 
the  absence  of  motor  paralysis,    and   the  other  signs  of  poliomyehtis 


Fig.  451. — Talipes  Equinovarus  (Moore). 


will  clear  up  the  diagnosis.  The  deformities  in  the  second  class 
are  the  result  of  paralysis,  which,  as  a  rule,  does  not  involve  all  of  the^ 
muscles  of  the  limb.  In  the  thigh  the  muscles  usually  involved  are 
those  of  the  anterior  and  internal  groups,  re- 
sulting in  a  flexion  of  the  hip  and  knee  (Fig. 
450).  There  is  often  a  subluxation  of  the 
tibia  backward  and  a  marked  genu  valgum. 

In  some  cases  there  is  hyperextension  of 
the  knee,  combined  with  fiat-foot. 

The  most  common  deformities  of  the  foot 
in  their-  order  of  frequency  are  (a)  tahpes 
ecjuinovarus;  (b)  calcaneo- valgus;  (c)  pes 
calcaneus  or  pes  cavus. 

The  third  form  of  infantile  paralysis  de- 
formities is  not  frecjuent.  The  most  com- 
mon is  dislocation  of  the  hip. 

The  diagnosis  of  all  of  these  paralytic 
deformities  depends  upon  the  recognition  of 
the  primary  disease,  viz.,  ]joliomyelitis  anterior.  Tlie  onset  is  usually 
sudden,  the  paralysis  is  of  the  flaccid  type,  there  is  marked  muscular  and 
often  bone  atrophy,  the  paralysis  usually  affects  only  one  limb  and  is 
not  hemiplegia.     The  reaction  of  degeneration  is  also  present. 


-Talu'ks  Equinu.s  (.Fow- 
ler). 


656 


THE    EXTREMITIES. 


Fig.  453. — Talipes  Calcaneus  (Fowler). 


Talipes  Equino- varus  (Club-foot i. 
This  is  a  deformity  of  the  foot  which  is  readily  recognized.     The 

majority  of  cases  are  of  congenital  origin.     In  a  small  number,  however, 

the  condition  is  an  acquired  one, 
usually  secondar}^  to  an  infantile 
paralysis.  The  foot  is  inverted 
and  rotated  upon  its  axis,  so  that 
the  outer  border  of  the  sole  touches 
the  ground  (Fig.  451)  and  the  toes 
point  inward.  The  front  part  of 
the  foot  is  at  the  same  time  de- 
pressed. The  head  of  the  astraga- 
lus and  cuboid  can  be  seen  to  pro- 
ject just  beneath  the  skin,  while 
the  inner  malleolus  cannot  be  felt. 
The  congenital  can  be  differ- 
entiated from   the  paralytic   form 

by   the   presence   of   paralysis   of    the   muscles   on   the   anterior   and 

external   surface    of   the   leg   in   the    latter.     The    tendo   Achilhs   in 

the  acquired  form  is  found  to  be 

very  tense. 

Talipes  Equinus. 
In  this  deformity  the  heel  is 
dravTi  up,  and  the  toes  point  down- 
ward. It  may  be  of  congenital  or 
acquired  origin.  The  former  is 
not  common,  the  usual  combina- 
tion being  that  of  equino-varus  or 
club-foot.  An  acquired  talipes 
equinus  may  follow  (a)  infantile 
paralysis,  (b)  disease  of  the  ankle- 
joint,  (c)  any  form  of  spastic  par- 
alysis (hemiplegia,  etc.),  (d)  frac- 
tures or  diseases  of  the  hip-  or 
knee-joints.  It  varies  in  degree. 
In    moderately    severe    cases   the 

patient  walks  upon  the  ball  of  the  foot,  i.  e.,  upon  the  heads  of  the  meta- 
tarsal bones.  The  toes  are  hyperextended  (Fig.  452).  Callosities  and 
bursse  frequently  form  over  the  ends  of  the  metatarsal  bones.     In  milder 


Fig.  454. — Typical  Flat-foot  (Gillellc). 


DEFORMITIES. 


657 


cases,  when  the  patient  attempts  to  walk  the  weight  is  borne  mainly 
upon  the  front  half  of  the  foot.  In  the  most  severe  forms  the  weight 
is  borne  entirely  on  the  dorsal  surface  of  the  metatarsals  and  toes,  the 
sole  of  the  foot  being  directed  backward. 

Talipes  Calcaneus. 

This  is  comparatively  rare  as  a  congenital  affection.  It  is  usually 
an  acquired  deformity,  and  follows  an  infantile  paralysis  of  the  mus- 
cles of  the  calf  of  the  leg. 

The  front  part  of  the  foot  (Fig.  453)  is  drawn  up  by  the  muscles 
of  the  front  of  the  leg.    The  patient  walks  upon  the  heel,  and  the  gait 
is  inelastic  because  the  spring  of  the  foot  is  absent.     It  is  generally 
associated  with  a  tal- 
ipes valgus  or  talipes 
cavus. 

Talipes  Cavus. 

This  is  a  condition 
in  which  the  arch  of 
the  foot  is  increased  so 
that  the  front  of  the 
foot  approaches  the 
heel  (Fig.  454).  It  is 
rarely  congenital.  In 
the  majority  of  cases  it 
is  an  acquired  deform- 
ity, the  result  of  an  in- 
fantile paralysis. 


Talipes  Valgus. 
This  i-s  one  of  the 
more    common     con- 


A  1; 

Fic.  ^55. — A,  Impression   of  Normal   Foot;   B,  Impression   of 

Flat-foot. 


genital  deformities  of 

the  foot.  The  arch  of  the  foot  is  entirely  lost,  the  sole  being  everted  so 
that  it  touches  the  ground  at  all  points,  and  finally  the  front  of  the  foot 
is  turned  out  (abducted).  Acquired  talipes  valgus  differs  from  an 
acquired  flat-foot  by  the  absence  of  a  distinct  dropping  of  the  arch  of 
the  foot.  Its  most  common  cause  is  an  infantile  s|)inal  paralvsis. 
It  is  much  less  painful  than  flat-foot. 

Flat-foot  (Pes  Planus). 
This  affection  is  most  common  during  adolescence,  and  is  essen- 
tially a  yielding  or  lowering  of  the  arch  of  the  foot.     The  instep  is 

42 


658 


THE    EXTREMITIES. 


unable  to  support  the  weight  of  the  body.  It  may  develop  either  gradu- 
ally or  acutely.  It  may  be  due  to  a  number  of  causes:  (a)  To  occu- 
pations requiring  prolonged  standing,  like 
that  of  waiters,  etc. ;  (b)  to  rheumatism,  es- 
pecially gonorrheal;  (c)  after  Pott's  frac- 
ture (Fig.  345);  (d)  as  a  compHcation  of 
rachitis;  (e)  weakness  of  the  muscles  of 
the  great  toe  and  head  of  the  first  metatar- 
sal bone ;  (/)  improperly  made  shoes,  with 
low  insteps;  (g)  rapid  growth  or  in- 
crease in  weight;  (h)  infantile  or  spastic 
paralysis. 

Clinically  it  can  be  readily  recognized 
if  close  attention  be  paid  to  the  normal 
condition,  and  also  to  the  fact  that  not 
every  painful  affection  of  the  foot  is  due 
to  '"rheumatism."  There  are  two  forms 
clinically:  (i)  Flexible  flat-foot  or  weak- 
ened foot,  where  the- flattened  position  is 
assumed  as  soon  as  weight  is  put  upon 
the  foot;  (2)  rigid  or  true  flat-foot,  in 
which  the  deformity  is  permanent,  owing 
to  alterations  in  the  structures  of  the 
bones.     The  condition  is  more  bilateral  than  unilateral. 

The  diagnosis  depends  upon  noting  any  lowering  of  the  arch  of 
the  foot  when  the  patient 
bears  the  weight  upon  it.  x^n 
impression  of  the  foot  should 
be  taken  by  allowing  the  pa- 
tient either  to  step  upon  card- 
board blackened  with  cam- 
phor smoke,  or  by  covering 
the  sole  of  the  foot  with  oil 
and  having  him  step  upon  a 
sheet  of  paper,  placing  the 
extra  weight  upon  the  foot.  ' 
A  variable  degree  of  pain 
is  present  in  the  neighbor- 
hood  of   the   scaphoid,   and 

often  it  is  also  referred  to  the  leg,  knee,  back,  or  hip.     In  the  milder 
cases  it  is  only  noticed  when  the  foot  is  stepped  upon.     In  the  more 


Fig.  456. — Hallux  Valgus   (Fowler). 


^ 


Fig.  457. — Appearance  of  Hand  in  a  Case  of  Webbed 

Fingers. 

The  index,  middle,  and  ring  fingers  are  bound  together  so 

that  they  can  only  be  distinguished  at  their  distal  ends. 


DEFORMITIES. 


659 


severe,  the  pain  is  constant,  and  independent  of  bearing  the  weight  upon 
the  feet.'  There  is  also  some  tenderness  over  the  most  painful  points, 
viz.,  over  the  scaphoid,  outer  border  of  the  foot,  center  of  the  heel,  front 
of  the  foot,  and  behind  the  inner  malleolus.  At  times  the  pain  and 
tenderness  seem  so  distinctly  localized,  that  an  inflammatory  focus  is 
thought  of. 

Inflammation  of  the  tendon-sheaths  of  the  peroneal  and  tibial 
tendons,  in  the  shape  of  elongated  soft  swelhngs  along  the  front  and 
sides  of  the  ankle,  are  often  the  symptom  for  which  the  physician  is 


Fig.   458.- 


-X-RAY   OF   Antero-posterior   View   of   Hand, 
,    SHOWING  Needle  in  Situ. 


Fig.  459. — X-RAY  OF  Lateral  View 
OF  Hand,  showing  Needle  in 
Situ. 


consulted.  In  very  acute  cases  the  foot  is  held  abducted  through 
contraction  of  the  peroneal  muscles.  The  foot  is  often  swollen,  and 
becomes  so  rigid  that  the  front  of  the  foot  cannot  be  adductcd  actively 
or  passively  as  much  as  it  can  normally  (Lovett). 

There  is  also  limitation  of  motion  in  the  ankle-joints.  When  the 
patient  walks,  the  feet  are  everted,  and  the  weight  is  borne  ujjon  the 
inner  side  of  the  foot.     There  is  a  lack  of  elasticity  in  the  gait. 

In  children  there  is  but  little  pain  on  walking.  The  physician  is 
often  consulted  Ijecause  the  cliild  tires  easily,  or  com])lains  of  pain  in 
the  legs,  back,  or  hips.     Rigidity  is  rarely  present.     The  chikl  cannot 


66o  THE    EXTREMITIES. 

balance  itself  well,  and  falls  frequently.     There  is  usually  a  greater 
degree  of  flattening  than  in  adults. 

Metatarsalgia  (MORTON'S  Disease). 
This  condition  is  characterized  by  frequently  recurring  attacks  of 
severe  pain,  which  usually  appear  between   the  third  and   fourth  or 


Fig.  460. — X-RAY  OF  Gunshot  Wound  of  Hand. 
Showing  bullet  embedded  on  metacarpal  bone  of  thumb. 


fourth  and  fifth  toes  while  the  patient  is  walking.  The  anterior  arch 
of  the  foot,  formed  by  the  heads  of  the  metatarsals,  is  often  relaxed 
or  flattened,  so  that  the  heads  of  the  second,  third,  and  fourth  meta- 
tarsal bones  are  on  a  lower  level  than  normal.  The  arch  of  the  foot 
is  often  flattened.  The  toes  are  often  rigid,  and  dorsal  flexion  of  the 
foot  may  be  limited. 


DEFORMITIES.  66 1 

Hallux  Valgus. 
This  is  a  deformity  of  the  great  toe,  in  which  the  phalanges  are 
pushed  outward  and  form  an  angle  with  the  head  of  the  metatarsal 
bone,  which  becomes  enlarged.  The  bursa  lying  over  the  latter  may 
become  inflamed  from  time  to  time,  and  be  present  as  a  tender,  soft 
swelhng  (bunion),  which  becomes  acutely  inflamed  at  intervals. 

Congenital  Deformities  of  the  Hands. 

Cluh-hand  is  usually  associated  with  other  deformities.  The  hand 
is  flexed  and  drawn  over  to  the  radial  side. 

Webbed  fingers  (syndactyhsm)  involves  two  or  more  fingers.  The 
union  extends  a  variable  distance  to  the  tips  (Fig.  457).  It  is  often 
associated  with  a  lack  of  development  of  the  bones  of  one  or  more 
fingers. 

Supernumerary  digits  (polydactyhsm)  are  also  congenital.  They 
are  generally  symmetrical  and  involve  hands  and  feet  (Fig.  457).  Usu- 
ally there  is  but  a  single  digit  in  excess,  on  the  side  of  the  little  finger 
or  httle  toe.  The  development  may  be  complete  or  more  or  less 
i-Tiperfect. 

Foreign  Bodies  in  the  Hands  or  Feet  (Figs.  458, 459, 46o). 
Various  foreign  bodies  may  penetrate  the  integument  and  remain 
embedded  in  the  subcutaneous  or  deeper  tissues.  The  most  frequent 
locations  of  these  are  the  hands  and  feet,  and  the  usual  substances, 
needles,  portions  of  a  bullet,  bits  of  glass,  etc.  The  most  reliable 
method  of  locating  these  is  by  the  use  of  the  .v-ray.  One  should  never 
depend  upon  a  fluoroscopic  view  of  their  location,  care  being  taken  to 
take  skiagraphs  in  two  directions.  This  method  is  to  be  especially 
recommended  for  needles. 


CHAPTER  VI. 
DISEASES  AND  INJURIES  OF  THE  SPINE. 

SPINA  BIFIDA. 

This  congenital  deformity  of  the  spine  occurs  most  frequently  on 
the  posterior  aspect,  less  often  on  the  ventral  or  anterior  surface.  Var- 
ious combinations  occur  as  the  result  of  a  non-closure  of  the  neural 
arches.     These  are: 

Rachioschisis. — This  is  due  to  a  complete  or  partial  absence  of 
union  of  the  medullary  canal.  This  is  the  most  severe  form.  There 
is  a  defect  of  normal  skin  in  which  an  open  depression  exists,  at  the 
base  of  which  a  soft  red  band  of  vascular  tissue  is  found,  which  repre- 
sents the  cord.  It  rests  upon  a  thin  reddish  membrane,  which  repre- 
sents the  pia  mater,  which  is  continuous  on  both  sides  with  the  skin. 
The  dura  and  arachnoid  he  beneath  it,  and  pass  over  into  the  subcu- 
taneous tissue.  The  arches  are  present  as  short  stumps,  and  the  bodies 
are  greatly  deformed. 

Myelocele  or  Myelomeningocele. — The  conditions  of  the  bones 
are  the  same  as  in  the  first  form  (rachioschisis),  but,  owing  to  the  accu- 
mulation of  fluid  between  the  membrane  on  the  ventral  side,  the  cord 
and  its  coverings  on  the  dorsal  aspect  are  pushed  out  and  form  a  visi- 
ble thin-walled  sac.  The  cord  hes  upon  its  inner  side  and  is  closely 
adherent  to  it.  As  in  the  first  form  there  is  a  defect  of  skin,  thus  favor- 
ing infection. 

Myelocystocele. — This  is  a  smaller  or  larger  sac  whose  outer 
covering  is  thin,  but  otherwise  unchanged.  The  innermost  layer  is 
composed  of  greatly  thinned  cord.  Between  it  and  the  skin  are  found 
two  thin  vascular  layers,  representing  the  pia  and  arachnoid.  This 
form  of  spina  bifida  is  the  result  of  the  accumulation  of  fluid  in  the 
central  canal,  and  the  dilated  cord  is  covered  by  pia-arachnoid  and  skin. 
The  dura  does  not  take  any  part  in  the  coverings  of  this  or  the  two 
preceding  forms. 

Meningocele. — In  this  form  a  cyst  with  a  narrow  pedicle  is 
found.  The  sac  is  either  composed  of  pia-arachnoid,  with  fluid  in  the 
subarachnoid  space,  or  only  of  dura,  with  fluid  in  the  subdural  space. 
The  cord  seldom  participates  in  the  formation  of  the  sac.  When 
it  does  the  condition  is  known  as  a  myelocele. 

662 


SPINA    BIFIDA. 


663 


The  diagnosis  0}  a  spina  bifida  itself  is,  as  a  rule,  not  difficult. 
The  majority  occur  on  the  posterior  aspect  of  the  spine  in  the  lumbo- 
sacral region  (Fig.  461).  Rachioschisis  and  myelomeningocele  can  be 
recognized  by  the  defect  in  the  skin.  In  both,  deformities  as  well  as 
paralyses  of  the  extremities  are  frequently  found,  with  or  without  in- 
volvement of  the  sphincters.  The  third  and  fourth  forms,  viz.,  myelo- 
cystocele and  myelomeningocele,  are  covered  by  normal  but  thinner  skin. 
The  first  named  is  often  associated  with  other  deformities,  such  as 


Ftg.  461.— Side  and  Front  Views  of  a  Case  of  Extensive  Spina  Bifida. 


hydrocephalus,  club-foot,  etc.  These  two  forms  can  only  be  distin- 
guished when  the  sac  is  opened.  In  a  meningocele  one  finds  a 
smooth  serous  inner  wall,  while  in  a  myelocystocele  there  is  a  red- 
dish-brown vascular  tissue  which  leads  into  the  open  cord.  ]\Ienin- 
goceles  are  rarely  accompanied  by  symptoms  of  ])aralysis.  When 
pressure  on  the  tumor  causes  the  fontanelles  lo  bulge  it  is  more  likely 
to  be  a  myelocystocele. 

Myelomeningoceles  are  usually  found   in  the  saci"uni,  while  myelo- 
cystoceles may  occur  an\\\here. 


664  DISEASES    AND    INJURIES    OF    THE    SPINE. 

INJURIES  OF  THE  SPINE. 
In  the  examination  of  a  patient  suffering  from  an  injury  to  the 
vertebral  column  either  recent  or  of  long  standing,  the  following  routine 
will  be  found  useful: 

1.  How  was  the  injury  received? 

2.  What  is  its  probable  nature? 

3.  Does  evidence  of  compression  or  destruction  of  the  cord  or  its 
nerves  exist? 

4.  At  what  level  did  such  injury  occur? 

5.  What  are  the  objective  evidences  of  such  injury,  exclusive  of 
that  of  the  cord? 

General  Consideration. — Before  discussing  spinal  injuries  in  detail 
a  brief  resume  of  our  present  knowledge  of  their  pathology  and  the 
chief  points  in  spinal  locahzation  will  be  taken  up. 

Pathology  of  Injuries  of  the  Spine. — Injuries  of  the  vertebrae 
usually  occur  in  adult  hfe  and  in  an  indirect  manner.  The  direct 
modes  of  injury  affect  the  arch,  while  the  indirect  involve  the  body  of 
the  vertebra.  Most  frequently  the  indirect  are  the  result  of  a  sudden 
bending  forward  (flexion)  of  the  spine.  Only  in  a  small  proportion 
of  cases  do  hyperextension  or  lateral  or  rotary  forces  play  a  role. 

Pure  fractures  are  quite  rare.  '  In  the  majority  of  cases  the  injury 
is  a  combination  of  a  fracture  and  a  dislocation.  Such  fracture  dis- 
locations are  most  apt  to  occur  between  the  tenth  dorsal  and  second 
lumbar  vertebras.  True  dislocation  without  fracture  is  most  apt  to 
occur  in  the  cervical  region. 

The  part  most  frequently  fractured  is  the  body  of  the  vertebrae. 

The  general  statements  on  page  438  in  regard  to  fractures  of  the 
bones  of  the  extremities  hold  true  for  those  of  the  vertebrae.  Com- 
pression fractures  are  more  common,  however,  than  in  the  case  of  any 
other  bones  except  those  of  the  tarsus  (Fig.  358).  The  compression 
may  be  so  extreme  that  the  upper  and  lower  intervertebral  discs  may 
be  brought  into  contact  with  each  other,  the  substance  of  the  bone 
being  partly  compressed  and  partly  displaced  upon  the  sides  or  behind 
into  the  spinal  canal  (Fig.  452). 

With  this  may  be  associated  fractures  of  the  arches,  spinous  and 
transverse  processes,  or  extensive  tears  of  the  ligaments. 

By  dislocation  of  a  vertebra  is  meant  an  injury  in  which  the  adjoin- 
ing articular  processes  on  one  or  both  sides  have  been  partly  or  com- 
pletely separated  from  each  other.  If  a  fracture  of  the  body  or  its 
arch   has  occurred   at   the   same   time  in   a   true   dislocation,  such   a 


INJURIES    OF   THE    SPINE. 


665 


fracture    can  be  deemed    unessential  to    the  production  of   the  dislo- 
cation. 

The  normal  range  of  motion  between  adjoining  vertebrae  is  in  two 
axes,  one  vertical  in  the  median  plane,  and  the  other  horizontal,  pass- 
ing through  the  posterior  part  of  the  disc.  There  are  two  modes  or 
varieties  of  dislocation,  viz.,  (a)  by  abduction,  which  includes  complete 
or  incomplete  unilateral  dislocations  forward  or  backward,  and  (b)  by 
flexion,  which  includes  bilateral 
dislocations  forward  or  backward. 

The  spinal  cord  terminates  at  the 
lower  border  of  the  body  of  the  first 
lumbar  vertebra.  It  is  made  up  of 
a  number  of  segments,  similar  and 
partly  independent,  which  corre- 
spond to  the  vertebral  bodies  and 
each  pair  of  spinal  nerves.  Ever}' 
segment  possesses  motor,  sensory, 
and  reflex  functions  besides  vaso- 
motor, visceral,  and  trophic  activi- 
ties. The  spinal  cord  may  be  in- 
jured directly  (a)  by  the  displace- 
ment of  a  fragment;  (b)  by  the 
pressure  of  a  dislocated  vertebra; 
(c)  by  a  blood-clot;  (d)  by  an  in- 
flammatory exudate;  {e)  by  elonga- 
tion; (/)  by  being  penetrated  by  a 
fragment  (rare);  (g)  by  being  pene- 
trated by  a  cutting  instrument  (stab 
wound)  or  a  bullet.  In  one  case  ob- 
served by  the  writer  a  piece  of  tin 
was  thrown  horizontally  in  such  a 
manner  as  to  enter  between  the  atlas 
and  skull  and  sever  the  cord. 

In  fractures,  the  cord  is  usually  caught  between  the  anterior  ])ortion 
of  one  fragment  and  the  posterior  portion  of  another  (Fig.  462). 

The  dura  is  seldom  torn,  the  cord  being  ])ulpiried  at  the  moment 
of  the  injury.  Hemorrhage  may  occur  either  around  llie  cord  (extra- 
dural), or  within  its  substance  (hematomyelia ). 

The  blood  in  the  former  case  spreads  up  and  down  in  the  canal, 
and  thus  compresses  llie  cord. 

In   hematomyelia    the   hemorrhage    may   lake   ]jlace   into   the   gray 


Fig.  462. — Fkactl'ke-dislocation  or  Spine, 
SHOWING  Crushing  of  the  Cord  (Guy's 
Hospit:il  Miisi-um). 


666  DISEASES    AND   INJURIES    OF   THE    SPINE. 

matter  alone  and  be  limited  to  a  few  segments,  or,  if  the  lesion  is  more 
severe,  the  hemorrhage  extends  into  the  white  columns.  If  the  patient 
survive,  the  absorption  of  the  clot  leaves  cavities  which  fill  with  scar 
tissue.  The  elements  of  the  gray  matter  are  thus  permanently  destroyed. 
Apparently  most  of  the  cases  of  injury  to  the  neck  which  recover  after 
having  presented  symptoms  of  severe  injury  to  the  cord  are  cases  of 
hematomyelia. 

Spinal  Localization. 

A  knowledge  of  the  functions  of  the  various  spinal  cord  segments 
is  absolutely  essential  to  the  diagnosis  of  surgical  lesions  of  the  cord. 
Such  cord  lesions  may  follow  (a)  the  pressure  of  a  fragment  in  fractures 
of  the  vertebra;  (b)  the  pressure  of  a  dislocated  vertebra;  (c)  hemorrhage 
into  or  around  the  cord ;  (d)  a  stab  or  gunshot  wound ;  (e)  pressure  of 
a  tumor  or  inflammatory  exudate. 

Cord  lesions  cause:  (a)  irritation;  (b)  partial  destruction,  or  (c) 
complete  destruction. 

(a)  Irritative  lesions  cause  hyperesthesia,  pain,  spasms,  rigidity, 
and  increased  reflexes. 

(b)  Partial  Destruction  of  a  Segment. — This  is  seldom  strictly  uni- 
lateral. If  only  one  lateral  half  of  the  transverse  cord  section  is  in- 
volved, as  occasionally  occurs  after  stab  wounds,  the  complex  symptom 
known  as  Brown- Sequard  paralysis  develops.  There  is  complete  loss  of 
power  on  the  same  side  as  the  lesion  in  all  parts  below  that  point. 
There  is  also  a  shght  loss  of  power  below  the  lesion  upon  the  opposite 
side.  Anesthesia  is  complete  on  the  side  opposite  the  lesion,  below  its 
level. 

There  is  a  band  of  cutaneous  anesthesia  upon  the  same  side  as 
the  lesion  which  marks  its  exact  level.  It  varies  vertically  accord- 
ing to  the  extent  of  cord  destroyed.  There  is  a  band  of  hyper- 
esthesia above  and  below  the  band  of  anesthesia  on  the  paralyzed 
side.  On  the  opposite  or  anesthetic  side,  there  is  also  a  band  of 
hyperesthesia  a  little  below  the  level  of  the  hyperesthetic  band  of  the 
paralyzed  side.  The  reflexes  are  increased  below  the  lesion  on  the 
paralyzed  side,  but  are  abolished  at  the  level  and  throughout  the  vertical 
extent  of  the  lesion. 

The  muscular  paralysis  in  these  partial  cross  lesions  is  usually  of 
a  spastic  character,  because  the  reflexes  are  preserved  and  increased 
as  just  stated. 

In  late  cases  of  partial  cross-lesions,  the  rigidity  and  spastic  features 


INJURIES    OF    THE    SPINE. 


66' 


are  well  developed  (Church).  The  lower  limbs  are  either  held  rigidly 
extended  or  less  frequently,  flexed.     Contractures  finally  develop  (Fig. 

463). 

(c)  In  total  destruction  0}  the  cord  the  symptoms  are  in  general: 
(i)  Paralysis  of  the  muscles  supplied  by  the  segment  involved  and  of  all 
muscles  represented  in  the  cord  below  the  lesion.  This  results  in  a 
paraplegia.  (2)  Anesthesia  in  the  area  of  skin  supphed  by  the  seg- 
ment and  in  all  parts  below.  This  is  really  the  best  guide  to  the  level 
of  the  lesion.  (3)  A 
zone  of  hyperesthesia  at 
the  upper  border  of  the 
area  of  anesthesia. 

In  the  trunk  total 
transverse  lesions  of  the 
cord  produce  an  anes- 
thesia whose  upper  limit 
is  horizontal,  while  le- 
sions of  the  nerve-roots 
cause  anesthesia  or  hy- 
peralgesia which  follows 
the  direction  of  the  in- 
tercostal nerves  and 
spaces,  (d)  The  reflexes 
furnish  very  valuable 
evidence  not  only  as  to 
the  upper  level  of  the 
cord  lesion,  but  some- 
times  as   to   its  vertical 

extent.  Complete  destruction  of  the  cord  extini^iiishes  all  reflexes  below 
the  level  involved,  while  partial  division  causes  an  enfeehlement  of  the 
same  reflexes,  which  later  on  is  succeeded  by  an  exaggeration  of  the 
same. 

The  absence  of  one  or  more  of  these  increased  reflexes  in  such  a 
case  points  to  the  level  of  the  lesion.  Again,  the  upper  level  of  abolished 
reflexes  usually  coincides  with  that  of  anesthesia,  and  cither  one 
enables  us  to  locate  the  lesion. 

(e)  Trophic  Dislurhances. — Tlie  extent  of  muscular  atrophy  depends 
upon  the  vertical  dimensions  of  a  lesion.  Thi'  musdes  innervated 
from  the  cord  above  and  below  the  destrucli\e  process  are  spared, 
and  regain  their  nutrition  and  electrical  reaction.     The  normal  galvanic 


Fig.  463. — Marked  Paralytic  Contractures  of  the  Lower  Ex- 
tremity Following  Compression  Myelitis,  due  to  Frac- 
ture OF  THE  Spine. 


668  DISEASES    AND    INJURIES    OF    THE    SPINE. 

response  gradually  disappears  in  the  atrophied  muscles  and  is  re- 
placed by  the  reaction  of  degeneration.  In  acute  destructive  lesions 
and  cord  hemorrhage,  acute  bedsores  may  form  in  a  few  hours  over  the 
sacrum,  heels,  malleoh,  and  trochanters  (Fig.  369). 

(/)  Vasomotor  Changes. — The  paralyzed  limbs  are  warmer  than 
normal,  and  there  is  distention  of  the  subcutaneous  veins.  Priapism 
is  a  very  common  sign  of  such  vasomotor  paralysis  in  lesions  of  the 
cervical  segments.  In  addition  the  latter  often  cause  flushing  and 
perspiration  on  the  side  of  the  neck  and  face  and  may  reduce  the 
heart-beats  to  forty  or  less  per  minute.  Dorsal  lesions  are  sometimes 
attended  by  a  persistently  rapid  pulse. 

ig)  Visceral  Symptoms. — There  is  usually  disturbance  of  the  anal 
and  vesical  sphincters.  When  their  reflex  centers  in  the  lumbar  cord 
are  destroyed  the  sphincters  are  completely  relaxed,  and  incontinence 
results.  If  the  lesion  is  abo^'e  their  spinal  center  only  voluntarv  con- 
trol is  lost.  This  results  in  retention  of  urine  and  feces.  The  disten- 
tion of  the  bladder  may  become  so  extreme  that  overflow  occurs, 
resulting  in  the  constant  dribbhng  of  urine.  This  latter  condition 
is  called  incontinence  of  retention. 

Cystitis  and  pyelonephritis  almost  invariably  follow  the  continued 
and  unavoidable  use  of  the  catheter  in  these  cases,  despite  every  pre- 
caution to  prevent  infection. 

The  retention  of  feces  present  in  the  early  stages  often  gives  way 
to  incontinence. 

Intestinal  obstruction,  of  the  variety  known  as  adynamic  ileus, 
may  develop  immediately  after  an  injury  of  the  spinal  cord.  It  may 
be  temporary  or  permanent,  the  latter  invariably  resulting  fatally. 

This  paralysis  of  the  intestinal  musculature  is  the  result  of  the 
involvement  of  the  splanchnic  nerves.  The  clinical  picture  in  such 
cases    resembles    that    described    under  intestinal   obstruction    (page 

277)- 

Acute  gastric  dilatation  may  also  develop  as  a  complication  of 
spinal  cord  injuries. 

A  study  of  the  accompanying  table  of  symptoms^  (pages  669  to 
675)  will  be  found  extremely  useful  in  the  diagnosis  of  the  level  of  a 
cord  lesion.  The  table  shows  the  clinical  signs  in  cases  of  disabling, 
but  not  absolutely  destructive,  cord  lesions.  If  the  entire  cross-section 
is  absolutely  destroyed  the  symptoms  are  the  same,  but  there  is  com- 
plete absence  of  muscle  reflexes  below  the  lesion. 

^Wichmann:  "The  Relations  of  the  Spinal  Nerves  and  Segments,"  Berlin.  1900. 


INJURIES    OF    THE    SPINE. 


669 


_- ~-.^_^ 

. ^^^^ 

• 

— .^ 

• 

x-o  J 

^ 

^~---- 

»-i          ■*-* 

2 

s 

a 

si's 

^ 

-^ 

0^ 

^^, 

.2     0 

lljll 

^^^^^^^\ 

>> 

o^a 

\ 

^^^^^^^ 

\s                                                                 \          i.                                V 

i-          ^  c/j  ; 

z 

III 

Q 

^ i 

/ 

s 

_^^^ 

in  A 

s 

"ci 

§ 

$^ 

c3 

50 

PM   ^ 

^ 

w5 

—  _o 

z 

"S   S 

5; 

0 

rt-l 

« 

H 

s 

(U 

oj 

L^ 

a 

C 

a 

^ 

S 

u 

0 

0 

0 

5 

u 

:z; 

2 

•Z. 

in 

, 

(2 

u 

w 

^-d 

Q 

p^ 

C 

°l 

C            '3 

0           "o 

i 

CCi 

< 

g:l 

^§^1 

0 

S 

'S  £ 

3'5|| 

u 

0 

u^ 

•as; -52  8 

'Z 

W                                        i 

WW     H 

uu 

DC 

■a 

H 

"d 

i 

0 

1 

C/0 

1— ( 

—             "                   D. 

z 

0 

w 

c 
c 

.0 

u 
p 

a 

«-.«-.  0   3  2 

fl  a  ^  °  u 

-6 

3 

d 
.0 

' 

CO 

< 

0 

0  0  S  c  — 

•B  -S  tj  0  d 

'1 

3^   3w                  -c 

1 

C/) 

0 

> 

3 

OJ 

0 

p^    WW         tL 

1 

U 

z 

z 

— 

0 

C/5 

0 

3 

z 

8 

.2 

■si      « 
.1     ^ 

H 
Q- 

at 

i 

•-  a  "■  M  3 

^ 

1 

(A 

S  =^  3  3  g  0 

1 
j 

>- 

3 

rt  !r-  >-,  1-  0.  M 

C/) 

M 

s-S  i^  rt  u  E 

S 

1 

U- 

>» 

3 

0 

0 

JcoQhWU 

(S 

w 

J 

OQ 

< 

(- 

>> 

■3 

3       =■«  3 

3 

a 

f* 

2  p     >.oi 

>     1         §?E 

0 

^ 

V       V            C  Z  0 

Z 

U                                  w 

W     Q         HWU 

zS 

0  3 

"rt 

.15 

■  "rt 

ui  a 

>  u 

^S 

w  0 

rt 

•^  rt 

J  a 

to 

tn 

I/) 

^, 

75 

670 


DISEASES    AND   INJURIES    OF    THE    SPINE. 


.2  >.S 

^^- 

^ 

3^2  2 

___ 

-**'53£^P 

ui 

■5'S'-' 

^A-^-^,^^^~^^^ 

0 

S-2'u 

X^^^^^'^'^'^^S 

iSSS^^JSSSSSTOS-P^w^rw** 

^^i 

39SSSsgS^SSSSSiSiK^ 

s 

\  ^  ~::^5 

^^^^^^ 

^SsssrJ      - 

^-i^^^^^^^ 

d 
>< 

u 

S  iS  c 
Ji  c3  0 

<^  2 

^^^^^^       —       ^<"^^^ 

^ 

^^^^^^^^^r""^^!. 

^---^i-i'f^^^^ 

•^^^^^^ 

^^^^ 

VVVv'^V^V^^^^^^^SSSSx^^V^^:^^ 

0 

z 
w 

CO 

-^ 

^ 

^^^^^^^^w 

■      « 

< 

rf 

t^ 

d 

a,  ^ 

C   £3 

1 

•-   0 

tn 

■^'s 

Z 
0 

1 

s 

OJ 

6 

l-i 

1— i 

a 
0 

0 
u 

« 

1 

.     1 

II 

P< 

II S 

^1  1  ..is 

Hal        J   0  •  C  5  -i 

0  u  c 

Cz^   0   0   oti   ^-^ 

•  ^  u  =^ 

d^(C.rf  ij.-'S^ 

S  <    i5"w  !S  Q  0 

wkS 

"^ 

"3 

Si   .-1 

m  S   3            S               S 

aj  3  "^         a            0 
^  U-,  TS           0            '5 

^^'^          -r,      ■         ° 

•2.2  g      -2-2     -^ 

g  g-^ii  1-3     E 
■St;  2-°  3  '^   1 

i   ^.2 
"o    "1 3 

1 
a 

B 

u 
0 

J 

!2 

0 

}■    111 

^   :s  c  g  g  ^ 

1- 

a 

0      dp     ■  S  "  " 

c    6  "  0  ><  Mo 
0    --i^o^^  jj- 

1 
0 

< 

2| 

c 
0 

1 

i^      tcic  0  c--,tl 
C      [«   in   CJ   >3   3m_ 

d   ■S'S"i=  o-a  0 

0      Oil^-^Pi 

Q(S 

oic^w      0       £ 

fa 

0.    CiOi       fa 

§ 

2 

1 

H 

S 

*o 

Z 

0 

CO 

z'*-''*^— "^                                      0 

' '  .    ■ . 

'' 

^ 

u 

8 

^  0  oi       ,~>^— .        [ft 

S  5  0        m 

3 

.""^ 

0 

H 
1 

g  £■::  .^  3 

to 

■i   Ills 2 

£  c  ^-^  aj  <u  £2  w 

§■■?  '^ 

■ft" J3  2  g  g-ii 

PHOOOKOcoh< 

c  c  C  w  c 

:^iy^-_o 

ftcic^r^fttSfaW 

^    ■ 

0  g 

'S-ji      *^S 

w 

C3^ 

U."    M 

j^  S  w   .'m'Si 

1 

K^ 

"d 

c  c 

3   c3  C3 

T3  ii  >-i  >-i  2  J  0. 

<faM>-;"<o 

-  .5  «  2  S 

a—  0^ 
rt-Q  bo 

"o  0  0.2 

0)   u  S  £ 
3  3   =■? 

^'  H 

2  a 

.■3 

"d 

5  a 

0! 

_d 

■J  '-i 

CO 

^v 

w 

INJURIES    OF    THE    SPINE. 


671 


PLiH 


,d 


t3   O 
>>  rt   O 


tG  -^ 


5    -^ 


£    2 


^    ^       ^  ^ 


5    E  Pi 


'0 

C 

0  »  2 

■& 

bo 

S 

E 

S-o^_ 

fl 

"0^2 

o_aj 

.2  c  S  f= 

M 

h^rii 

a 

±i 

s  s 

£  p   MO 

rt 

'3  '-'' 

faW 

^ 

!^ 

V.  o 


E  -c 


Q^a    o      w  Pi 


id  i3      ii       d     d       K 

fa  cu      ti      Pi    Pi      W 


s.|.2.E|iJ';;3  2  3 

u)  tn   C   C   g^   3   ci  g  J2  rs 

=  =:335u3to,/;  a  := 

OJ    (U^^    3    3jJ    5j    rtT?  K  :2 


m   ■  =^  ,,;  3 

g  «i  S  Ex!  E 

>2  sJ.S  o  o  o  ^ 

23333  3^ 


3  1-  « 

si's 
csS  to 


'o'c'c 


3  3  3  ^2 


3  3 
d      '3 

■J,    ^.    'A  ^   B-ji    „.    •/)    y.  •^    S    3    3   S 

wu7(5j3'^c-iw-^   t- — •— ;3  w   3  2 
P  3  3^  f  ^,2.2.2.  u  3  C  g  ■'   ' 


O   3   3 

5  5  C  3  3' 

S  Si  «J  o   o. 


3Sca.OOOOSt«iy3euOt^SwcH&,h 


liiE 


672 


DISEASES    AND    INJURIES    OF    THE    SPINE. 


O 


S      § 


.3  >.§ 

ex- 
'    of 
rnal 
pes- 

0 

N          _^ 

1-  ^  <u  >, 

•sfll 

'S       .S  3 

a  >>62 

^^ 

H 

5 

0 
u 

0 

_^^^^^^^ 

^ 

■1 

^^^^^^^^^^^ 

^ft 

2 

-"f^  s-s 

^^^^ 

W 

3Ji-Sg^ 

Q«^       U„ 

0 

H 

[3 

a) 

.S 

a 

"t; 

E 

tu 

tH 

Pi  ^ 

^ 

0 

e  S 

3 

5- 

a         3 

T3  tn 

s^  . 

0    .      3 

3-B        0 

0 

1^ 

^   oJ   rt 

i,   m  l^   '^ 
^   oi  d   ^ 

p 

1— 1 

3  J:!  3 

<D  (_  d  ^4 
"S  "^  d 

z 

< 

<     S 

Pt,        PL,< 

0 
0 

X 

w 

J 

h 

w 

c 

u 

0 

0 

p^ 

"i- 

"C 

^ 

•  -S 

•    ■  -^ 

-w     • 

< 

•06 

CL,0 

■^9  E 
eL,<;o 

IS 

•                     1^        g" 

r^ 

oJ 

3        ~      ' 

;3 

■d 

0             -" 

D.            -^j 

)h 

'S 

S            S 

0, 

p. 

0 

S 

0 

1          S  S3 

-i 

a 

13        3  s 

^ 

s 

0 

J^      .S-^ 

J 

s 

.0 

1   1l 

0 

•43 

0 

< 

1    ii- 

0 

E 

< 

z 

a 

■  0 

P 

2 

OJ 

^ 

z 

5 

i 

^^-a^ 

« 

U 

m   ■     15 -S, 

g 

f2 

3.a    -.£f 

0 

g  0      0* 

s 

3  3  j;  3  0 

«  0  3  T3   >< 

pI]  ■ 

M-.    +J 

0   cfi 

V 

0   D, 

o§ 

■V 

en   u 

'f^  S9 

-a       .      J 

11 

0  >» 

1^ 

=3'E 

sl 

(S 

3  rt  3  g -g  _a;  rt  _aj  ^ -55  JS 
S      0 1-5  Oi  ti-.  eu  ^4  Cd  U  > 

0  u 

1    -^ 

.2 

pa 

^  H 

^ 

iJ 

1^ 

z  Z 

rt 

S 

cit 

c  w 

^Xi 

•-Q 

.  J3 

5;  a 

HE 

K  E 

"E 

w  0 

3 

3 

3 

^c^ 

J 

uj 

INJURIES    OF    THE    SPINE. 


673 


.ss 


£  I-  S  ^      M  > 

°  &     — ^ 

«  G  cs      o  te  i;    . 

o  ft  S  0-3       O'^ 

<L)  rt  jh  rt_  u  o 

A  :3 


"oj  ft  o 
-So' 

< 


^  s  >  s  . 

§•2  oiixi 

ft  ftTj  ft  g 

^  S-=  E  " 

^  ^      S"o 

O    <; 


d  to 
o  a 


a  a.<u 
^  5  1=1 


d  nJ  C 


S.2 


d        O        '"    • 


'^■■^  .--.2 

g=j2  a  ■  d  ft  0. 

g  !:«:  d  g  c  g  g 

iiw2l:i  3  2  o  o 


T  i2 


43 


Q 


«i2 


674 


DISEASES    AND   INJURIES    OF   THE    SPINE. 


<5 


« 

o 
o 

K 

O 
m 
o 


o 
« 


Pi  ^ 

o  S 


o    < 


w 


w5< 


^-2  o 


^^ 

"V.  is 

ii 

03 

B 

C3 
0 

s 

o 

0 

> 

<U^P^< 

"o 

nj 

a 

g 

0 

•    Jh    r- 

S^ 

ts  o  g 


O 
Eh 
ft 

>^ 

O 

H 

<i 


.       ■  B 

M'd  g  o 


■D.f„-§"5'.B- 
^■^     B  £ 


■5  B-M 

°  g  S  a 
£  c  >j 


•S  in  >-.        fl.t! 
O-^  C     .  0,^   m 

^  Ji  «  S^  g  g 

OJ  o  o^      >^ 
>>T-,  w  u  t-,  3  c   r! 

■g^^^ga^g 

d.     <<;foO!=li-! 


C  "en       „  ^ 


, • ,T3  .*- 


3  o  b  o  £• 


333gBd.£*o- 


'■3 


QJ 


e   -2- 


"b^-S  3i 

£         3   ^  3   p.-a 


^   .J  '5.73 

ft  c  -  - 


-M 


f-  d  V. 


h  a 


3  2 


—  EC 


>5 


O 


INJURIES    OF    THE    SPINE. 


675 


—  c 


«._,        <^  <u 


u  '^ 


a. 2 


O      •      O   O   oj  CI 

".2    "sort     -ri 

t3  ■"    T3  "^ -^   d        O 


-2| 


.2'S 

■M 

rt 

Wi    i_ 

—   0 

D--S  "=> 

S  d   S. 

oZ  a  a 
QwwQ 


-SB      ° 

3   "  il   3   M  g 
o  ^  0.0       ■"  ^ 


3 

■^■e|o|?l 

bo 

riragm 
nts   frc 
nt   of 
spread 
4th  cer 
ezius  a 
d  are  i 

s"a 

.§■  e  6  s  s  2° 

>  "rt 

H-]C>3 

Q              H 

2"    TS  . 

>. 

P  o-o"2 

extremi 

s   (indu 
d   hand 

- 

K 

f  the  ar 

and    ti 

e    delto 

us. 

1 

fe-S 

3 

e  muscles  0 
arm,    hand. 
;     even    th 
cobrachialis 
hialis  antic 

3 
B 

es  of  lo 
trunk. 

es  of  fi 
thumb) 

alls  ma; 
mus  do 
major. 
Dinatus. 

E 

_o 

"0 

"d   . 

uscl 
and 
use] 
ing 

-1^2 

CJ 

3 

C 
d 

I  th 
fore 
gers 
cora 
brae 

&t 

!S    S 

r-i 

(i!jh  ° 

CO 

!S 

< 

q£ 

CJ 


^1 

HI    V 
U 


676  DISEASES    AND    INJURIES    OF    THE    SPINE. 

Lesions  of  the  Cauda  Equina. — The  cauda  equina  is  made  up 
of  the  descending  roots  of  lumbar,  sacral,  and  coccygeal  nerves.  It 
is  about  ten  inches  in  length.  It  is  affected  by  the  same  lesions  as  the 
spinal  cord  itself.  The  sensory,  motor,  trophic,  and  reflex  symptoms 
are  the  same  as  follow  division  of  the  indi^ddual  nerve-trunks.  In 
partial  lesions,  sensation  may  be  but  slightly  disturbed  when  motion 
is  quite  lost.  Increased  reflexes  are  not  encountered.  The  lowest 
portion  of  the  cauda  is  usually  involved,  and  the  lesions  cease  at  some 
definite  upper  level.  ]Most  cord  lesions,  on  the  other  hand,  are  Hmited 
in  vertical  extent,  and  the  reflex  and  trophic  disorders  are  confined 
to  the  corresponding  body  segments. 

In  the  examination  of  an  individual,  for  the  purpose  of  making 
a  diagnosis  of  an  injury  of  the  spine  and  spinal  cord,  the  various  con- 
ditions which  require  consideration  are:  (i)  Fractures;  (2)  dislocations; 
(3)  hematorachis  and  hematomyelia;  (4)  concussion  of  the  spine; 
(5)  traumatic  spondylitis.  "^ 

Fractures  of  the  Spine. 

A  true  fracture  of  the  vertebral  column  without  accompanying 
dislocation  is  so  infrequent  that  the  term  "fracture-dislocation"  would 
be  more  appropriate.  Their  diagnosis  can  be  best  considered  in  con- 
nection with  the  individual  regions. 

Of  the  Upper  Two  Cervical  Vertebrae  (Atlas  and  Axis).  —  Three 
classes  of  cases  occur  clinically,  viz. :  (a)  Those  in  which  death  is  immedi- 
ate, and  no  diagnosis  can  be  made  as  to  whether  fracture  or  dislocation 
existed.  (&)  Those  in  which  death  occurs,  weeks  to  months  after  the 
injury,  as  the  result  either  of  a  secondary'  myelitis  or  after  a  sudden 
movement  of  the  patient.  In  the  absence  of  paralysis  a  diagnosis  cannot 
be  made  in  these  cases,  (c)  Those  in  which  no  symptoms  exist,  and 
the  nature  of  the  injury  often  remains  unrecognized.  These  last  named 
cases  are  usually  diagnosed  as  sprains.  They  complain  of  pain  in  the 
neck  and  it  is  held  rigid. 

It  was  formerly  thought  that  practically  all  of  the  cases  of  fracture  or 
dislocation  of  the  atlas  or  axis  belonged  to  the  first  group,  i.  e.,  where 
death  was  immediate.  According  to  Gurlt,  these  constitute  the  min- 
ority. 

In  the  second  group,  where  the  patient  survives  and  the  symptoms 
of  secondary  myelitis  appear,  the  diagnosis  can  be  made  from  the 
latter,  and  is  occasionally  confirmed  by  the  palpation  through  the 
mouth  of  the  displaced  vertebra  at  the  level  of  the  bony  septum.  In 
some  cases  the  paralysis  involves  all  of  the  parts  below  the  fracture. 


I^7^RIES  OF  the  spixe.  677 

In  others  there  is  only  partial  paralysis,  and,  in  one  case,  only  a 
shght  diminution  of  sensibility  in  the  left  arm. 

From  the  Third  Cervical  to  the  Second  Dorsal  Vertebra  In- 
clusive.— In  this  region  one  must  distinguish  fractures  of  the  body 
from  those  of  the  arch.  If  the  latter  occur,  there  is  crepitus  or  irreg- 
ularity of  the  spinous  processes.  In  respect  to  the  latter,  it  must  not 
be  forgotten  that  the  third  and  fourth  cervical  spines  normally  lie  quite 
deeply. 

In  fractures  of  the  body  an  abnormal  prominence  can  often  be 
felt  through  the  pharynx. 

The  position  and  mobility  of  the  head  vary  greatly.  It  is  held 
rigid  in  the  majority  of  cases,  the  shoulders  being  dra\Mi  up  and  the 
neck  shortened.  In  some  cases  the  head  can  be  moved  freely  to  either 
side,  but  not  forward  or  backward. 

As  a  rule,  symptoms  of  pressure  upon  the  spinal  cord  appear  early. 
Thev  may  be  due  to  (a)  a  hemorrhage  into  or  around  the  cord,  or  (b) 
compression  by  a  fragment  or  displaced  vertebra. 

If  no  spinal  symptoms  occur  a  differential  diagnosis  can .  only  be 
made  by  an  x-ray  examination,  and  the  fact  that  the  symptoms  persist 
for  a  longer  period. 

If  the  third  to  fifth  cervical  vertebree  are  broken,  death  either  occurs 
from  paralysis  of  the  phrenic  nerve  or  the  diaphragm  acts  only  two' 
or  three  times  a  minute,  accompanied  by  a  very  slow  pulse. 

The  extent  of  the  peripheral  paralysis  accompanying  compression 
of  the  cord  in  this  region  varies.  Paralysis  of  the  arms  is  not  as  constant 
as  one  would  expect.  Often  the  paralysis  only  extends  to  the  level 
of  the  umbihcus  or  breast.  The  paralysis  of  the  arms  is  quite  often 
absent.  In  some  cases  the  paralysis  of  the  arms  may  appear  upon  the 
day  after  the  accident,  or  even  later.  It  may  involve  only  one  arm 
or  a  single  group  of  muscles. 

In  some  cases  there  is  great  dyspnea,  especially  during  expiration, 
as  a  result  of  paralysis  of  the  intercostal  and  abdominal  muscles.  In 
other  cases  there  is  marked  difficulty  in  speech  and  swallo\Aing. 

There  may  be  paralysis  of  sensation  or  of  motion  alone.  Hy- 
peresthesia of  part  or  all  of  the  arm  is  at  times  observed,  as  well  as 
tonic  and  clonic  spasms.  Other  symptoms  of  injury  to  this  region 
are  vasomotor  changes  in  the  face  and  neck,  priapism,  and  a  high 
temperature.  In  rare  instances  the  vertebral  artery  has  been  torn, 
a  large  clot  forming  between  the  muscles  of  the  neck.  In  some  cases 
the  x-ray  has  proved  to  be  of  great  -Calue.  The  question  as  to  whether 
the  cord  symptoms  are  due  to  compression  of  a  fragment  or  of  a  dis- 


678  DISEASES    AND    INJURIES    OF    THE    SPINE. 

located  vertebra,  or  whether  they  are  due  to  hematomyelia,  will  be 
considered  later  (page  682). 

Fractures  from  the  Third  to  the  Twelfth  Dorsal  Vertebrae. — 

The  diagnosis  of  fractures  in  this  region  is  not  very  difficult.  The 
arch  is  rarely  involved.  Usually  the  bodies  (Fig.  462)  of  one  or  more 
vertebras  are  involved  with  direct  compression  of  the  cord.  In  the 
majority  of  cases  the  condition  can  be  recognized  (a)  by  the  symptoms 
of  spinal  cord  compression  plus  (b)  the  local  evidences  of  injury.  In 
some  cases  the  compression  symptoms  may  exist  without  a  discernible 
deformity,  and  again  there  are  instances  where  the  gibbus  or  angular 
deformity  is  quite  marked  and  yet  no  paralysis,  etc.,  exists.  The  spinal 
cord  symptoms  may,  as  in  the  case  of  injuries  higher  up,  be  due  to  the 
compression  of  a  blood-clot  (page  681). 

As  a  rule,  the  arms  escape  paralysis.  In  the  most  typical  cases 
there  are  (a)  paralysis  of  motion  in  the  lower  extremities  (paraplegia); 
(b)  paralysis  of  the  bladder  and  rectum,  resulting  in  retention  of  urine 
and  feces;  (c)  anesthesia  to  the  level  of  the  injured  vertebras  (pages 
673  and  674);  (c/)  paralysis  of  the  abdominal  and  intestinal  muscles. 
As  is  the  case  in  all  spinal  injuries,  these  are  subject  to  great  variation. 
The  motor  paralysis  may  be  irregular  or  even  absent.  The  paralysis 
of  the  abdominal  muscles  causes  the  breathing  to  be  shallow  and  dia- 
phragmatic. 

The  tympanites  resulting  from  the  paralysis  of  the  abdominal 
muscles  and  that  of  the  intestinal  musculature  may  become  so  extreme 
as  to  cause  death  from  a  paralytic  or  adynamic  ileus  (page  283). 

Locally  the  diagnosis  of  fractures  in  this  region  is  greatly  aided  if 
an  angular  deformity  or  a  distinct  hiatus  be  found.  The  spines  may 
be  abnormally  separated  or  prominent,  or  may  crepitate.  This  can 
be  best  elicited  by  passing  the  finger  along  the  spinous  processes.  The 
majority  of  these  patients  die  from  an  ascending  pyelonephritis  in 
spite  of  the  utmost  precautions  taken  to  prevent  infection  during 
catheterization.  Those  who  survive  often  show  marked  contrac- 
tures. 

Fractures  of  the  Lumbar  Vertebrae. — Fractures  in  this  resrion 
decrease  in  frequency  from  above  downward,  those  of  the  last  three 
vertebrae  being  very  rare.  Only  the  first  lumbar  is  frequently  broken. 
The  symptoms  are  chiefly  those  of  pressure  upon  the  cauda  equina  (page 
670),  since  the  spinal  cord  ends  opposite  the  lower  border  of  the  first 
lumbar  vertebra.  Paralysis  is  often  absent,  and  if  it  is  present  it  re- 
sembles that  of  injuries  of  the  'individual  peripheral  nerves.  The 
paralysis  of  the  extremities  is  often  unequal  or  irregular,  being  con- 


INJURIES    OF    THE    SPINE.  679 

fined  to  flexors  of  the  thigh  and  leg.  Anesthesia  is  present  in  a  similar, 
irregular  manner.  There  are  often  sharp  pains,  referred  along  the 
course  of  the  peripheral  nerves,  and  paresthesia.  Reflexes  are  either 
absent  or  are  only  feebly  present.  Muscular  atrophy  appears  very 
early.     Vesical  and  rectal  paralysis  is  frequently  present. 

Dislocations  of  the  Vertebrae. 

A  dislocation  of  a  vertebra  is  defined  as  an  injury  in  which  the 
articular  processes  of  one  or  both  sides  have  completely  separated  from 
each  other,  accompanied  by  more  or  less  displacement  of  the  body. 
The  term  diastasis  is  applied  by  Blasius  to  those  dislocations  in  which 
the  ligaments  and  intervertebral  discs  are  so  torn,  that  the  vertebrae 
are  separated  from  each  other  in  front  or  behind,  in  a  longitudinal 
direction.  They  are  not  displaced  on  each  other  horizontally,  so  as 
to  separate  the  articular  surfaces  from  each  other  completely,  as  in 
the  case  of  a  true  dislocation. 

True  dislocations  are  most  frequent  in  the  cervical  region,  quite 
rare  in  the  dorsal,  and  rarest  of  all  in  the  lumbar  region.  We  usually 
speak  of  the  upper  of  the  two  vertebr£e  as  the  dislocated  one.  A  dias- 
tasis is  most  apt  to  occur  between  the  fifth  and  sixth  or  the 
sixth  and  seventh  cervical  vertebrEe.  It  is  often  combined  with  a 
fracture.  Dislocations  of  the  vertebrae  are  best  divided  into  (a)  dis- 
locations by  abduction  or  rotation,  and  (b)  dislocations  by  flexion. 
Under  those  by  abduction  or  rotation  are  included  the  complete  or 
incomplete  unilateral  dislocations  forward  or  backward,  and  the  bilateral 
dislocations  in  opposite  directions.  The  majority  of  the  unilateral 
are  forward,  there  being  only  a  few  cases  recorded  in  which  it  occurred 
in  a  backward  direction.  Under  dislocations  by  flexion,  are  included 
bilateral  forward  or  backward  ones.  The  former  is  far  more  frequent, 
and  follows  extreme  flexion  of  the  neck.  There  are,  as  in  the  case  of 
the  unilateral  abduction  variety,  but  few  cases  of  bilateral  backward 
dislocations.  The  diagnosis  of  this  class  of  injuries  of  the  vertebras, 
viz.,  dislocations,  is  very  difficult.  The  majority  of  the  symptoms 
are  local,  and  there  is  little  to  distinguish  them  from  a  fracture.  The 
evidences  of  displacement  are  the  same,  but  there  is  no  crepitus  as  in 
fracture.  The  latter  sign  may,  however,  be  absent  even  in  a  fracture. 
Abnormal  mobility  might  also  be  of  value  in  (lie  dilTercntialion  from 
a  fracture,  were  it  not  for  the  fact  that  the  neck  is  held  so  rigid  that 
it  is  impossible  to  ehcit  abnormal  mobility  or  crepitus,  and  further  it  is 
contraindicated  to  manipulate  the  spine  under  these  conditions. 

The  neck  is  held  rigid  and  contracted  in  both  fractures  and  dislo- 


68o 


DISEASES    AND    INJURIES    OF   THE    SPINE. 


cations.     The  chief  diagnostic  points  of  a  dislocation  are  (a)  the  de- 
formity;   (b)  the  pain,  and  (c)  the  spinal  cord  symptoms. 

(a)  The  deformity  can  often  be  recognized  by  passing  the  finger 
along  the  cervical  spines,  and  also  by  palpating  the  transverse  processes. 
The  prominence  or  depression  of  a  spinous  process  is  often  quite  marked, 
allowance  being  made  for  the  fact  that  one  can  seldom  feel  the  upper 
cervical  spines  even  in  normal  individuals.  At  times  the  displaced 
vertebrae  can  be  felt  through  the  pharynx  (Fig.  464). 

(b)  The  pain  varies  greatly,  but  is  generally  quite  marked,  and 
referred  along  the  course  of  the  affected  cervical  nerves. 


Fig.  464. — Fracture  and  Subluxation  ;   Cervical  Vertebra  United  (J.   Mason  Warren   collection, 

Warren  Museum)  (Walton). 


(c)  The  spinal  cord  symptoms  may,  as  in  the  case  of  a  fracture, 
be  due  to  hematomyeha  or  to  the  pressure  of  a  fragment  or  displaced 
vertebra.  The  symptoms  of  compression  are  absent  in  a  larger 
number  of  cases  of  dislocation,  than  of  fracture;  especially  is  this  true 
of  paralyses.  If  present,  they  are  apt  to  be  less  extensive  and  less 
marked  than  in  the  case  of  a  fracture.  Immediate  death  may  occur 
as  the  result  of  phrenic  nerve  paralysis.  In  general,  however,  the 
paralyses  are  incomplete,  and  anesthesia  is  often  absent  or  unequal. 
It  may  be  more  marked  on  one  side  than  the  other.  The  paralysis  may 
correspond  entirely  to  that  of  a  peripheral  nerve.     Paralyses  may  be 


INJT^^RIES    OF   THE    SPINE. 


68i 


quite  marked  and  then  disappear  gradually.  In  some  cases  the  para- 
plegia, paralysis  of  the  rectum  and  bladder,  priapism,  high  temperature, 
vasomotor  changes,  and  acute  decubitus  may  resemble  the  same  symp- 
toms following  a  fracture  (page  668). 

Other  nervous  symptoms  are  localized  muscular  twitchings,  general 
epileptiform  convulsions,  hyperesthesia,  and  neuralgic  pains  in  the 
course  of  nerves  that  are  compressed. 

The  x-ray  may  be  of  some  value  in  confirming  the  diagnosis,  but 


Fig.  465. — X-RAY  OF  Normal  Adult  Spine  in  Cervical  Region. 
The  outlines  of  the  upper  four  cervical  vertebrae  are  traced  in  white  and  marked,  i,  2.  3,  and  4.  respectively. 

care  must  be  used  in  interpreting  the  skiagraph.  X-rays  shown  in 
Fig.  465  were  taken  from  a  normal  individual,  one  without  any  effort 
at  displacement,  and  the  second  (Fig.  466)  following  extreme  voluntary 
efforts  of  flexion.  They  were  taken  to  pro\X'  the  possil)ility  of  a  normal 
x-ray  resembling  that  of  a  dislocation. 


Hematorachis  and  Hematomyelia. 
These    conditions    are    so    frequently    associated    after    traumatism 
that  they  will  be  descriljcd   together.     Meningeal  hemorrhage   (hem- 


052  DISEASES    AND    INJURIES    OF   THE    SPINE. 

atorachis)  may  be  extradural  or  subdural.  The  symptoms  of  both  are 
alike.  In  hematomyelia  the  hemorrhage  usually  takes  place  into  the 
gray  matter,  but  the  white  matter  is  not  exempt.  Both  of  these  con- 
ditions occur  most  frequently  in  the  cervical  region. 

The  symptoms  of  hematorachis,  when  it  occurs  alone,  appear  more 
gradually  than  do  those  of  hematomyelia.  In  both,  the  symptoms 
depend  upon  the  tension,  extent,  and  location  of  the  clot. 

The  symptoms  common  to  both  conditions  are  the  following:  (a) 
Severe  pain  radiating  along  the  compressed  or  involved  nerve-trunks; 


Fig.  466. — Pseudo-dislocation  of  Normal  Atlas  upon  Axis  Secured  by  Protruding  Head  Volun- 
tarily Forward.     (See  text.) 


(b)  symptoms  of  motor  and  sensory  paralysis;  (c)  paralysis  of  the 
bladder  and  anal  sphincters. 

The  symptoms  of  hematomyeha  are  present,  as  a  rule,  immediately 
after  an  injury,  and  this  is  the  only  feature  distinguishing  it  from  hem- 
atorachis. 

In  traumatic  cases  the  two  are  so  frequently  associated  that  it  is 
almost  impossible  to  make  a  differentiation. 

The  symptoms  are  usually  most  marked  at  the  end  of  the  first 
twenty-four  hours.     They  subsec^uently  improve,  and  disappear  com- 


INJURIES    OF    THE    SPINE.  683 

pletely  in  four  to  six  weeks.     Death  may,  however,  immediately  re- 
sult. 

Both  of  these  conditions  can  be  distinguished  from  the  spinal  cord 
symptoms  following  fractures  or  dislocations  by  the  fact  that  they 
develop  more  gradually,  and.  further,  that  they  tend  to  disappear 
spontaneously  within  a  short  time. 

Concussion  of  the  Spine. 

This  condition  has  been  the  subject  of  considerable  dispute  ever 
since  Erichsen,  in  187 1,  pubhshed  his  treatise  on  "Spinal  Concussion." 

He  described  fifty-three  cases  of  spinal  injury,  received  chiefly 
during  railway  accidents,  which  had  no  external  evidence  of  such 
injury.  The  list  embraced  cases  of  fracture,  hematomyeha,  meningitis, 
hysteria,  and  neurasthenia.  To  these  he  gave  the  name  "railway 
spine,"  and  this  term  is  extensively  employed  by  lawyers  for  litigants, 
even  at  the  present  time,  to  represent  an  imaginary  clinical  entity. 

Oppenheim,  in  1880,  made  a  closer  distinction  between  organic 
injuries  and  those  not  marked  by  histologic  changes,  and  proposed 
the  term  "traumatic  neuroses"  for  the  latter  class.  About  the  same 
time  Charcot  taught  and  demonstrated  that  the  nervous  symptoms 
in  these  cases,  apart  from  those  attributable  to  organic  lesions,  were 
precisely  the  same  as  are  presented  in  neurasthenia  and  hysteria.  The 
latter  two  conditions  may  develop  after  a  fright,  or  after  a  railway  or 
other  accident.  They  do  not,  however,  differ  in  any  degree  in  their 
symptoms  or  diagnosis  from  a  neurasthenia  or  a  hysteria,  which  do  not 
follow  trauma.  Many  of  the  symptoms  develop  immediately,  and  are 
so  greatly  improved  after  the  settlement  of  a  claim  for  damages  as  to 
have  caused  them  to  be  termed  litigation  symptoms. 

In  some  cases  there  is  distinct  simulation.  A  celebrated  case  is 
that  of  a  patient  who  claimed  to  have  had  a  dislocation  of  the  atlas 
upon  th€  axis,  and  had  typical  hysterical  blindness,  and  paralyses 
of  motion  and  sensation,  shifting  from  one  limb  to  the  other.  X-rays 
were  shown  in  court  which  accurately  resembled  such  a  dislocation. 
X-rays  were  taken  of  a  normal  individual  (Fig.  468),  and  it  was  shown 
that  it  was  possible  to  reproduce  exactly  the  sym])toms  of  the  claimant, 
who  had  voluntarily  thrown  the  head  forward  while  ha\-ing  a  skiagraph 
so  as  to  simulate  a  dislocation.  For  the  diagnosis  of  neurasthenia  and 
hysteria  the  reader  is  referred  to  text-books  on  ner\-ous  diseases. 

Traumatic  Spondylitis. 
This    interesting    post-traumatic  condition  was    first    described    by 
Schede  and  later  by  KiimnKJl.     ll  is  in  reality  a  softening  of  the  ver- 


684  DISEASES    AND    INJURIES    OF    THE    SPINE. 

tebral  body  following  an  injury,  with  the  gradual  yielding  of  the  body 
and  resultant  angular  deformity.  It  follows  injuries  of  the  same  nature  as 
those  which  cause  the  other  post-traumatic  lesions  previously  described. 
The  distinctive  feature  of  the  disease  is  the  fact  that  pain  along  the  com- 
pressed nerves  appears  months  to  years  after  the  injury.  Accompany- 
ing these  pains  there  are  often  paralyses  of  varying  degrees,  and  the 
gradual  development  of  an  angular  deformity,  or  gibbus,  similar  to 
that  observed  in  tuberculous  spondyHtis  (page  688).  In  some  cases 
there  is  a  general  increase  of  the  curve  of  the  spine.  In  these  cases 
the  diagnosis  cannot  be  made  until  the  deformity  or  paralysis  appears, 
which  occurs  a  considerable  period  after  the  injury. 

The  chief  conditions  from  which  it  must  be  differentiated  are  sim- 
ulation and  a  tuberculous  spondyhtis.  The  former  is  excluded  by  the 
objective  evidence  of  the  angular  deformity  or  general  increase  of  the 
curve  of  the  particular  region  involved.  The  tuberculous  condition  is 
more  frequent  in  early  life,  accompanied  by  muscular  spasm  and 
abscess  formation,  and  there  is  less  tenderness  than  in  traumatic 
spondylitis. 

Gunshot  and  Stab  Wounds  of  the  Spine. 

The  symptoms  and  diagnoses  of  both  of  these  forms  of  injury  do 
not  differ  from  those  of  other  traumatic  conditions.  Stab  wounds 
usually  cause  contusion  of  the  cord,  producing  in  the  majority  of  cases  a 
partial  paralysis  of  the  Brown-Sequard  type  (see  page  666). 

Half  of  the  cord  is  not  always  severed,  but  the  surrounding  degen- 
eration produces  the  remainder  of  the  symptoms. 

In  gunshot  wounds  one  finds  the  symptoms  of  fracture  of  the  body 
of  the  vertebra  plus  those  of  paralysis,  or  the  signs  of  fracture  of  the 
arch  or  spinous  process.  One  cannot  tell  whether  the  paralysis  is  due 
to  the  bullet  itself  or  to  compression  by  a  sphnter.  The  x-rsij  may  be 
of  some  aid  in  this  direction. 

The  cord  symptoms  differ  in  no  manner  from  those  following  ordi- 
nary fractures  or  dislocations  of  the  vertebrae.  They  may,  however, 
disappear  entirely. 

Diseases  OF  the  Spine. 

TUBERCULOUS  SPONDYLITIS  (POTT'S  DISEASE). 
This  and  scoliosis  are  the  two  most  frequent  non-traumatic  affec- 
tions of  the  spine.     It  rarely  involves  any  other  part  of  the  vertebra 
than  its  body,  producing  a  gradual  disintegration  of  the  latter.     In 
about  half  of  the  cases,  an  abscess  is  found  chnicahy,  whose  pus  gravi- 


TUBERCULOUS    SPONDYLITIS. 


685 


tates  along  intermuscular  planes,  from  the  original  focus.  These 
abscesses  usually  present  externally  in  certain  definite  places,  according 
to  whether  the  primary  disease  is  in  the  cervical,  dorsal,  or  lumbar 
regions  (see  below).  The  destruction  of  two  or  more  adjacent  vertebrae 
results  in  the  formation  of  one  of  the  most  typical  signs  of  the  disease, 
viz.,  an  angular  deformity  (see  below).     A  comphcation  of  the  disease 


Fig.  467. — Method  of  Examination  of  the  Head  and  Neck  in  order  to  Determine  the  Presence  of 
AN  Inflammatory  Affection  of  the  Upper  Cervical  Vertebra. 
The  surgeon  should  stand  behind  the  patient,  grasping  the  head  between  the  extended  hands,  the  fin- 
ger-tips being  placed  below  the  lower  jaw.  The  head  is  then  caused  to  bend  forward  and  backward,  elicit- 
ing pain  during  these  movements.  Such  evidence  of  pain  is  ordinarily  not  to  be  obtained  in  these  cases  of 
disease  of  the  atlas  or  axis,  on  account  of  the  voluntary  fixation  of  the  spine  on  the  part  of  the  patient. 


is  its  extension  to  the  membranes  of  the  spinal  cord,  the  resulting  pachy- 
meningitis giving  rise  to  pressure  symptoms  of  varying  degree. 

Primary  disease  of  two  verteljral  bodies  in  different,  non-adjacent 
parts  of  the  spine  is  rare.  The  two  most  frequent  locahzations  of  a 
tuberculous  spondylitis  are  in  the  twelfth  dorsal  and  first  lumbar 
(dorsolumbar  junction)    vertebrae,  and    next    in   order  in  the  seventh 


686 


DISEASES    AND    INJURIES    OF   THE    SPINE. 


cervical  and  first  dorsal  vertebrae  (cervicodorsal  junction).  The  most 
important  diagnostic  symptoms  of  the  disease  are:  (i)  The  reflex  rigidity 
of  the  spine;  (2)  the  referred  pains;  (3)  the  presence  of  an  angular  or 
more  gradual  deformity;  (4)  the  formation  of  abscesses;  (5)  the  symp- 
toms of  spinal  cord  involvement.  Of  these  the  presence  of  the  promi- 
nence, associated  with  muscular  rigidity,  and  its  resultant  attitudes  and 
gaits  are  sufficient  to  make  a  diagnosis  if  the  diseases  to  be  described 

{malignant  tumors,  frac- 
tures, etc.)  are  excluded. 
I.  Rigidity  of  the 
Spine. — If  the  disease  is 
located  in  the  upper 
cervical  region  (atlas  or 
axis)  the  head  and  neck 
are  either  held  in  a  wry- 
neck attitude  or  the 
head  is  rigidly  fixed  in 
the  median  line.  Every 
eilort  to  rotate  the  head 
or  to  flex  the  head  upon 
the  neck  (Fig.  467)  is 
resisted,  or  accompan- 
ied by  great  pain.  The 
patient  attempts  to  fix 
the  head  voluntarily,  by 
supporting  the  chin  up- 
on the  hands. 

In  disease  of  the 
lower  cervical  or  upper 
dorsal  region,  the  chin 
is  held  raised,  the  mus- 
cles of  the  back  of  the 
neck  and  of  the  back 
itself  are  contracted  and 
cause  the  spine  to  be  held  stiff  and  straight.  It  is  difficult  for  the  patient 
to  lean  forward  or  to  pick  up  objects  from  the  floor. 

In  disease  of  the  lower  dorsal  and  upper  lumbar  vertebras  the  mus- 
cles of  the  back  can  also  be  felt  to  be  contracted.  The  spine  is  held 
rigid,  and  this  is  most  marked  when  the  patient  bends  over  or  walks. 
The  gait  is  characteristic.  In  the  effort  to  fix  the  spine  the  patient  will 
throw  the  shoulders  and  head  back,  and  walk  by  sliding  the  feet  along 


Fig.  468. — Method  of  Tapping  Head  in  Order  tu  Determine 
Tender  Points  in  Spine. 


TUBERCULOUS    SPONDYLITIS. 


687 


the  floor,  so  as  to  move  the  pelvis  and  the  lumbar  spine  as  little  as 
possible.  There  is  also  flexion  at  the  hip  (Fig.  469),  and  the  patient 
steps  on  the  toes.  In  disease  of  the  cervical  and  upper  dorsal  region 
the  patient  walks  with  head  fixed  in  the  median  Hne,  shoulders  raised, 
and  spine  erect. 

The  rigidity  in  the  dorsolumbar  region  is  best    tested  by  raising 
the  Hmbs  while  the  pa- 
tient lies  prone  upon  the 
table. 

2.  Pains. — The  pain 
of  Pott's  disease  is  more 
often  referred  to  distant 
points  than  to  the  dis- 
eased vertebra.  It  is  usu- 
ally referred  to  the  ter- 
minations of  the  corre- 
sponding spinal  nerves. 
In  diseases  of  the  cervi- 
cal region,  the  pain  is  re- 
ferred to  the  back  of  the 
head  or  neck,  or  to  the 
mastoid  region,  or  along 
the  arms.  In  disease  of 
the  dorsal  and  lumbar 
vertebrae,  the  pains  are 
referred  to  the  peripheral 
ends  of  the  correspond- 
ing intercostal  and  ab- 
dominal nerves.  It  is 
not  uncommon  for  such 
patients  to  complain  of 
stomach-ache,  pains  like 
those  of  a  pleurisy,  inter- 
costal neuralgia,  or  lumbago,  or  pain  in  the  bladder,  etc.  The  pains 
are  always  worse  at  night,  and  arc  increased  by  any  movements  of  the 
spine.  In  some  cases  the  pain  is  elicited  by  tapping  upon  the  head 
(Fig.  468)  or  pressing  upon  the  spines. 

3.  Dejormity. — This,  when  present,  is  sufficient  to  make  a  diagnosis. 
In  acute  cases  there  is  accompanying  muscular  spasm  and  referred 
pains,  while  in  subacute  or  chronic  cases  the  deformity  is  usually  present 
without  rigidity,  and  the  pain  is  minimal. 


Fig.  469. 


Method  of  Palpation  of  the  Spinous  Processes  ' 
FOR  Tenderness.     (See  text.) 


DISEASES    AND    INJURIES    OF   THE    SPINE. 


The  deformity,  or  gibbus,  as  it  is  called,  may  be  quite  sharp  and 
cause  an  angular  prominence  of  the  spines  of  only  two  or  three  vertebrae, 
or  it  may  involve  a  number  of  vertebra.  The  curve  in  the  latter  in- 
stance, is  a  more  gradual  one. 
This  is  especially  apt  to  be 
so  in  the  more  chronic  cases. 
Accompanying  this  angular 
deformity  there  are  marked 
changes  in  the  contour  of  the 
head  and  thorax,  as  well  as  a 
retardation  of  the  general  body 
growth. 

4.  Abscesses. — x\lthough  at 
autopsy  a  collection  of  pus  is 
invariably  found,  it  can  be 
recognized  clinically  in  only 
one-half  of  the  cases.  In  cer- 
vical disease,  the  abscess  is 
found  either  in  the  retropharyn- 
geal space  or  in  the  lateral  re- 
gions of  the  neck.  In  the  latter 
location  it  simulates  an  abscess 
having  its  origin  in  caseous 
lymph-nodes,  but  is  usually 
larger  and  accompanied  by  the 
spinal  symptoms — rigidity  and 
pain  on  movement. 

In  disease  of  the  dorsal  re- 
gion the  abscess  may  appear 
upon  the  back  and  simulate  a 
lipoma  (Fig.  134),  or  an  abscess 
having  its  origin  in  disease  of 
the  ribs.  Disease  close  to  the 
dorsolumbar  junction  causes  ab- 
scesses which  may  appear  (a)  in 
the  lumbar  region  over  the  kid- 
ney, or  (b)  above  Poupart's  hga- 
ment,  simulating  a  reducible  oblique  inguinal  hernia,  or  (c)  over 
Scarpa's  triangle,  simulating  a  femoral  hernia  (Fig.  471).  In  the  two 
latter  locations  the  detection  of  fluctuation,  the  absence  of  an  impulse  on 
coughing,  and  the  spinal  symptoms  soon  clear  up  the  diagnosis. 


Fig.  470. — Kyphosis  at  Dorsolumbar  Junction,  due 
TO  Tuberculosis  of  the  Last  Dorsal  and  First 
Lumbar  Vertebra. 

K,  Points  to  apex  of  kyphosis,  or  backward  angle  of 
deformity  of  spine;  P,  points  to  a  large  psoas  abscess, 
the  anterior  view  of  which  is  seen  in  Fig.  471. 


TUBERCULOUS    SPONDYLITIS. 


689 


5.  Spinal  Cord  Symptoms. — These  are  an  infrequent  complication, 
but  occur  especially  often  in  the  more  acute  cases.  The  motor  paraly- 
sis is  usually  the  most  marked  symptom.  It  varies  from  weakness  to 
complete  loss  of  power.  The  paralysis  is  at  first  of  the  flaccid  type, 
but  later  spasticity  with  resul- 
tant contractures  occur.  The 
paralysis  sets  in  gradually,  but 
may  increase  rapidly,  with  ex- 
acerbations. It  often  improves 
with  betterment  of  the  local 
condition. 

In  upper  cervical  disease  the 
arms  and  legs  are  both  para- 
lyzed, and  there  may  be  dys- 
phagia, etc.  In  these  cases 
death  may  occur  suddenly,  fol- 
lowing spontaneous  dislocation 
of  the  atlas  upon  the  axis.  The 
sensory  paralysis  is  very  atypical 
because  the  posterior  portions  of 
the  cord  are  but  httle  involved. 
There  may  be  anesthesia  or  hy- 
peresthesia, or  only  paresthesia. 
The  reflexes  are  exaggerated  at 
first,  but  later  are  absent. 

In  addition  to  the  chief  diag- 
nostic features  of  tuberculous 
spondylitis  just  enumerated, 
viz.,  rigidity,  pains,  deformity, 
abscesses,'  and  paralyses,  it  is 
of  great  value  to  obtain  a  his- 
tory of  tuberculosis  in  the  family 
or  of  foci  elsewhere  in  the  body 
(lymph-nodes,  joints,  lungs,  kid-  - 
ney,    testis,    peritoneum,    etc.). 

The  general  condition  shows  quite  marked  changes.  The  ])atients  arc 
emaciated  and  anemic.  There  is  a  difference  between  morning  and 
evening  temperatures  of  from  one  to  three  degrees. 

Differential  Diagnosis.— IFry-wec^.— Disease  of  the  cervical  spine 
must   be   differentiated    from    the    various    forms   of    wry-neck.     The 
principal  features  of  the  rheumatic,  congenital,  and  inflammatory  forms, 
44 


Fig.  471. — Enormous  Psoas  Abscess  over  Scarpa's 
Triangle  in  Boy  Suffering  from  Tuberculous 
Spondylitis  of  the  Dorsolumbar  Region. 


690 


DISEASES    AND   INJURIES    OF   THE    SPINE. 


the  last  named  from  inflamed  lymph-nodes,  have  been  fully  considered 
on  page  150. 

Diseases  close  to  the  dorsolumbar  junction  must  be  differentiated 
from  the  following  conditions: 

Hip  Disease. — This  has  been  considered  on  page  632.     The  re- 
striction of  motion  at  the  hip  in  Pott's  disease  is  in  only  one  direction, 

viz.,  hyperextension,  owing  to 
contraction  of  the  psoas.  The 
lumbar  spine,  although  held 
somewhat  rigid  in  hip  disease, 
as  a  compensatory  condition,  is 
arched  and  less  fixed  than  in 
Pott's  disease. 

Other  Forms  0}  Backward 
Curvature  or  Kyphosis. — -Rachitic 
kyphosis  is  a  gradual  one  extend- 
ing over  the  entire  dorsal  and  lum- 
bar regions.  There  is  no  muscu- 
lar rigidity,  and  there  are  always 
other  signs  of  rachitis  (see  page 

590). 

Senile  kyphosis  (Fig.  114)  in- 
volves chiefly  the  dorsal  vertebrae, 
and  is  also  gradual.  There  is  no 
rigidity  or  pain.  Other  condi- 
tions which  require  differentiation 
are  scoliosis  (page  691),  hysterical 
spine  (page  692),  arthritis  defor- 
mans of  the  spine  (page  691),  ma- 
lignant disease  (page  693),  and  acute  osteomyehtis  of  the  spine  (page  691 ). 


JL 


Fig.  472. — Scoliosis. 
Showing  principal  curvature  to  right  in  dorsal 
region,  and  compensatory,  in  opposite  direction,  in 
lumbar  and  cervical  regions.  The  prominence  of  the 
posterior  portion  of  the  thorax  well  marked  on  side 
of  curvature.  The  difference  in  the  contour  of  the 
chest  also  to  be  noted. 


SCOLIOSIS  (LATERAL  CURVATURE  OF  THE  SPINE). 
This  is  an  affection  which  appears  during  the  years  of  growth,  i.  e., 
from  the  sixth  to  the  sixteenth  years.  Often  the  first  complaint  is  from 
the  parents,  who  have  noticed  that  the  child  carries  one  shoulder  higher 
than  the  other.  In  the  majority  of  cases  the  diagnosis  can  be  readily  made 
by  inspection  from  behind  when  the  patient  is  divested  of  the  clothing 
down  to  the  level  of  the  hips  (Fig.  472).  The  most  frequent  curve  of 
the  spine  is  that  in  which  there  is  a  convexity  in  the  dorsal  region,  to  the 
right  (right  dorsal  scohosis).     The  right  shoulder  is  higher,  the  scapula 


ACUTE    OSTEOMYELITIS    OF   THE    SPINE.  69I 

on  the  side  of  the  convexity  stands  out,  and  is  also  higher  than  its  oppo- 
site. The  thorax  below  the  scapula  on  the  same  side  is  more  rounded, 
and  there  is  a  corresponding  enlargement  on  the  left  side  of  the  front 
of  the  thorax. 

There  is  a  much  wider  space  between  the  right  arm  and  the  side  of 
the  trunk  than  on  the  left  side.  If  the  spines  of  the  vertebrae  are  marked 
with  ink  the  curvature  becomes  quite  clear.  There  are  always  com- 
pensatory curves  in  the  opposite  direction  above  and  below  the  primary 
one  (Fig.  472).  The  cervicodorsal  and  lumbar  curvatures  are  less 
frequent  than  the  dorsal.  Lateral  curvature  may  result  from  various 
causes,  viz.:  (i)  Rachitis;  (2)  a  sequela  of  infantile  paralysis;  (3) 
torticollis;  (4)  occupation;  (5)  chest  diseases,  especially  after  empyema; 
(6)  a  sequela  of  sciatica;  (7)  as  a  result  of  faulty  posture.  The  latter 
is  the  most  frequent. 

ARTHRITIS  DEFORMANS  OF  THE  SPINE  (SPONDYLITIS  DEFORMANS). 

This  occurs  as  a  part  of  the  general  disease  of  the  joints  previously 
described  (page  615).  As  elsewhere  its  chief  clinical  features  are  pains 
and  gradually  increasing  stiffness  of  the  spine.  Gonorrhea  is  a  not 
infrequent  cause.  The  disease  occurs  oftenest  in  elderly  persons,  but 
may  be  one  of  the  manifestations  of  a  generalized  arthritis  deformans 
at  any  age  (Fig.  413).  The  patients  at  first  complain  of  pains  like 
those  of  rheumatism,  especially  referred  along  the  cervical  and  branchial 
nerves.  This  stage  is  soon  followed  by  gradually  increasing  rigidity, 
most  marked  in  the  cervical  region.  The  patient  is  unable  to  flex  or 
rotate  the  neck.  In  some  cases  flexion  is  possible,  but  there  is  inabihty 
to  extend  the  neck  (Fig.  414). 

In  many  cases  the  cervical  region  is  the  last  to  be  affected,  the  lower 
part  of  the  spine  being  first  involved.  The  spinal  rigidity  is  often  accom- 
panied by  the  same  condition  in  the  hips.  There  is  no  angular  deformity 
as  in  Pott's  disease,  the  whole  spinal  column  is  more  apt  to  be  involved, 
and  there  is  no  tendency  to  abscess  formation.  Spondylitis  deformans 
is  a  frequent  complication  of  gonorrhea.  The  diffuse  stiffness  of  the 
spine,  the  slight  backward  curve,  the  presence  of  the  same  conditions 
in  the  hip,  knee,  and  other  joints,  as  well  as  the  absence  of  muscular 
rigidity,  are  the  chief  diagnostic  points. 

ACUTE  OSTEOMYELITIS  OF  THE  SPINE. 
This  rather  rare  affection  presents  no  difficulties  of  diagnosis.     The 
onset  is  a  sudden  one,  with  severe  pain,  high  fever,  tenderness  on  prcs- 


692  DISEASES    AND   INJURIES    OF    THE    SPINE. 

sure,  and  muscular  rigidity.  The  formation  of  abscesses  occurs  early, 
and  is  indicated  by  the  appearance  of  redness,  induration,  and  heat  in 
the  vicinity  of  the  affected  vertebrae. 


TYPHOID  SPINE. 
This  appears  during  convalescence  from  typhoid,  and  is  most  apt 
to  involve  the  lumbar  portion  of  the  spine.  There  is  localized  tenderness 
and  pain.  Disturbances  of  sensation,  such  as  paresthesia  and  hyper- 
esthesia, are  frequent.  The  diagnosis  can  be  made  from  an  acute 
form  of  tuberculous  spondylitis,  by  the  absence  of  angular  deformity,  and 
of  abscess  formation,  as  well  as  from  the  history  of  a  preceding  typhoid. 


HYSTERICAL  SPINE. 

This  occurs  oftenest  as  the  result  of  an  injury,  and  has  been  pre- 
viously discussed  under  the  head  of  spinal  concussion  (page  683).  It  is 
a  local  spinal  manifestation  of  a  general  neurasthenia.  By  careful 
and  repeated  examinations  one  can  readily  eliminate  any  or  all  of  the 
other  forms  of  genuine  spinal  disease. 

There  is  complaint  of  tenderness,  which  is  often  greatly  exaggerated. 
There  is  no  true  rigidity,  although  some  may  be  feigned,  and  can  be 
discovered  when  the  attention  is  diverted.  Pressure  over  the  same 
spinous  process  will  at  one  examination  be  said  by  the  patient  to  be 
very  painful  and  later  not  noticed. 


TUMORS  OF  THE  SPINE  AND  SPINAL  CORD. 

Neoplasms,  whether  they  arise  from  the  vertebrae,  from  the  meninges, 
or  from  the  cord  itself,  can,  as  a  rule,  only  be  recognized  hy  the  symptoms 
resulting  from  pressure  upon  the  spinal  nerves  and  cord. 

Schlesinger  has  recently  collected  151  cases.  Of  these  104  involved 
the  vertebrae  primarily,  4  grew  into  the  spinal  canal  from  without,  11 
arose  from  the  dura,  4  from  the  pia-arachnoid,  5  from  the  nerve-roots, 
and  20  were  intramedullary. 

As  a  rule,  all  of  these  tumors  are  of  more  diagnostic,  than  therapeutic 
interest.  The  majority  of  those  which  arise  from  the  vertebrae  are  of 
secondary  carcinomatous  nature.  The  latter  are  frequent  after  primary 
growths  in  the  breasts,  thyroid,  and  i)rostate.  I'hose  which  are  not 
metastatic  are  primary  fibromata  or  sarcomata  of  the  bodies.  The 
most  frequent  meningeal  and  intramedullary  growths  are  the  gumma, 


TUMORS    OF    THE    SPINE    AND    SPINAL    CORD. 


693 


tubercle,  glioma,  and  sarcoma.  The  gliomata  give  rise  to  a  clinical 
picture  described  as  syringomyelia  (page  624). 

The  first  symptom  to  attract  the  attention  of  the  patient,  in  all  of 
these  neoplasms,  is  pain. 

The  pains  afl'ect  a,  single  spinal  nerve  or  a  pair.  Often  a  persistent 
unilateral  or  bilateral  intercostal  neuralgia  is  one  of  the  earliest  symp- 
toms.    At  first  the  pains  are  mild,  but  may  become  sharp  and  lancinat- 


FiG.  473. — Cutaneous  Nerve  Supply  to  the  An- 
terior Surface  of  the  Body  (Seiffer). 


Fig.  474. — Cutaneous  Nerve  Supply  to  the  Pos- 
terior Surface  of  the  Body  (Seififer). 


ing,  or  remain  as  a  constant  dull  ache.  These  pains  are  at  first  accom- 
panied by  hyperesthesia  over  the  area  of  distribution  of  the  nerve. 
This  neuralgic  stage  may  persist  for  months  to  years,  and  the  patient 
be  treated  for  neurasthenia,  etc.,  until  signs  of  motor  irritation  and 
paralysis  appear.  The  symptoms  of  motor  irritation,  like  twitchings, 
spasms,  and  rigidity,  are  soon  replaced  by  muscular  weakness  and 
finally  by  complete  paralysis.     The  latter  is  at  first  apt  to  affect  only 


694  DISEASES    AND   INJURIES    OE   THE    SPINE. 

one  extremity,  but  the  opposite  one  is  soon  involved,  so  that  a  para 
paresis  or  paraplegia  develops. 

The  sensory  symptoms  most  frequently  correspond  to  the  Brown- 
Sequard  type  (page  666),  but  the  anesthesia  is  also  frequently  bilateral. 

The  reflexes  below  the  level  of  the  lesion  are  markedly  increased, 
and  this  exaggeration  follows  the  paralysis  closely,  the  reflexes  being  lost 
when  the  compression  is  total.  There  is  early  involvement  of  the  sphinc- 
ters of  the  bladder  and  rectum,  as  well  as  the  development  of  extensive 
decubitus.     To  locate  the  seat  of  the  tumor  a  knowledge  of  the  areas 


Fig.  475. — Fistula  of  Coccygeal  Region  Leading  into  a  Dermoid  Cyst. 
The  arrow  points  to  the  black  spot  which  represents  the  opening  of  the  fistula. 

of  cutaneous  sensation  supplied  by  the  various  spinal  segments  is  of  the 
greatest  importance  (Figs.  474  and  473),  as  showing  the  upper  levels 
of  the  dysesthesia. 

The  diagnosis  depends  upon  a  knowledge  of  the  more  or  less  regular 
order  and  gradual  appearance  of  the  symptoms,  viz.:  (a)  Neuralgic 
pains;  (b)  monoplegia,  later  paraplegia;  (c)  anesthesia;  following 
motor  paralysis;  (d)  exaggerated,  and  absence  of  reflexes.  The  presence 
or  history  of  a  primary  growth  elsewhere  is  of  great  value. 

From  Pott's  disease  malignant  disease  can  be  differentiated  by  the 


SACROCOCCYGEAL   TUMORS.  695 

fact  that  the  deformity  when  present  is  not  angular,  as  in  Pott's  disease, 
but  more  rounded.  In  those  tumors  which  arise  from  the  cord  itself 
there  is  no  deformity,  only  neuralgic  pains  and  muscular  stiffness.  The 
pains  are  never  as  severe  in  Pott's  disease  as  in  tumor.  The  symptoms 
of  tumors  of  the  cauda  equina  do  not  differ  from  those  of  injuries  of 
the  same  (page  670). 


SACROCOCCYGEAL  TUMORS. 
A   number  of  interesting  congenital   conditions   are  found  in  the 
region  of  the  sacrum  and  coccyx.     They  may  be  of  three  varieties: 

1.  Teratomata. — -These  are  irregular,  pendulous  tumors  attached  to 
the  posterior  surface  of  the  sacrum  or  coccyx.  In  one  class  rudiments 
of  the  skeleton  and  of  the  different  viscera  are  found.  These  are 
remnants  of  a  parasitic  fetus,  which  has  failed  to  develop.  In  another 
class  there  is  a  great  variety  of  tissues  which  do  not,  however,  represent 
any  single  organ. 

2.  Cystic  Tumors  Behind  the  Rectum. — These  are  found  between 
the  rectum  and  sacrum.  The  majority  have  their  origin  in  persistent 
remnants  of  the  post-anal  gut  and  neurenteric  canal.  The  unilocular 
variety  form  large  cysts,  and  may  project  into  the  rectum.  The  multi- 
locular  form  is  made  up  of  a  number  of  cysts,  each  containing  a  rope- 
like substance  resembling  mucus.  Dermoids  also  occur  within  and  be- 
hind the  rectum,  and  may  attain  a  large  size. 

3.  Sequestration  Dermoids. — These  occur  over  the  sacrum  and 
coccyx,  and  allied  to  them  are  the  sinuses  and  dimples  which  occur  here 
(Fig.  475).     The  sinuses  open  near  the  tip  of  the  coccyx. 


CHAPTER  VII . 

POSTOPERATIVE  COMPLICATIONS. 

These  have  assumed  such  importance  at  the  present  time,  when 
the  scope  of  operative  interference  has  been  so  greatly  extended,  that 
the  abihty  to  recognize  them  at  an  early  period  renders  it  advisable  to 
add  a  chapter  on  the  subject.  They  may  be  divided  in  one  of  two 
ways,  viz. : 

A.  According  to  the  individual  operations  ox  regionally,  i.  e.,  the 
part  of  the  body  operated  upon. 

B.  According  to  the  most  prominent  symptom  or  the  organ  in- 
volved in  the  complication. 

The  latter  classification  seems  the  most  satisfactory  from  a  diag- 
nostic point  of  view  and  will  be  followed  here.  According  to  this  mode 
of  division  the  most  important  postoperative  complications  are: 

1.  Hemorrhage. 

2.  Shock  and  collapse. 

3.  Infection,  not  including  peritonitis. 

4.  Pulmonary  complications. 

5.  Cardiac  complications. 

6.  Hepatic  complications. 

7.  Gastro-intestinal    complications,  including    postoperative    ileus 
and  peritonitis. 

8.  Postoperative  ileus. 

9.  Postoperative  peritonitis. 

10.  Renal  comphcations. 

11.  Circulatory  comphcations  (thrombosis,  etc.). 

12.  Miscellaneous  postoperative  complications. 


HEMORRHAGE. 

Hemorrhage  following  an  operation  may  occur  from  the  wound  itself 
in  one  of  three  ways: 

(a)  As  the  result  of  imperfect  hcmostasis,  either  from  hgating  bleed- 
ing vessels  too  loosely  or  not  having  secured  a  sufficient  number  of 
bleeding  vessels,  the  temporary  closure  by  clots  being  disturbed  through 

movements  of  the  patient. 

696 


HEMORRHAGE.  697 

(b)  As  the  ]-csult  of  constitutional  causes.  In  this  group  belong 
those  unavoidable  hemorrhages  which  occur  as  the  result  of  hemophiha 
and  long-continued  jaundice. 

(c)  As  the  result  of  infection  of  the  wound.  The  thrombi,  which 
obliterate  the  cut  ends  of  the  vessels,  become  disintegrated  as  the  expres- 
sion of  a  purulent  softening  due  to  microorganisms.  This  was  formerlv 
called  secondary  hemorrhage  and  was  far  more  f recjuent  than  at  present, 
when  septic  infection  is  rare. 

Hemorrhage  may  take  place  after  operations  either  (a)  in  such  a 
way  that  it  can  be  recognized  at  once  by  the  reddish  staining  of  the 
dressings,  accompanied  by  increasing  symptoms  of  anemia,  i.  e.,  external 
hemorrhage,  or  {h)  there  may  be  no  escape  of  blood  from  the  w^ound 
or  the  latter  may  not  be  accessible  to  observation.  Such  postoperative 
bleeding  is  apt  to  follow  intraabdominal  operations  or  those  upon  the 
stomach  or  rectum. 

These  last-named  hemorrhages  may  be  properly  termed  concealed  or 
internal,  since  they  can  only  be  diagnosed  by  recognizing  the  symptoms 
characteristic  of  internal  hemorrhage  in  general,  viz.,  those  of  rapidly 
increasing  anemia  and  the  other  symptoms,  such  as  recurrent  attacks  of 
syncope,  thirst,  restlessness,  and  rapid,  empty  pulse. 

The  diagnosis  of  the  actual  existence  of  the  first  chnical  variety, 
viz.,  external  hemorrhage,  presents  no  difficulty.  The  blood  is  seen 
escaping  either  in  large  quantity,  or  there  is  constant  oozing  which  fre- 
quently resists  all  of  the  ordinary  methods  of  treatment.  At  times  a 
gradually  increasing  hematoma  may  be  the  expression  of  this  form  of 
postoperative  hemorrhage. 

In  cases  where  the  hemorrhage  is  due  to  constitutional  causes,  like 
hemophilia,  inquiry  into  the  previous  history  of  the  patient  himself  or 
of  the  family  will  often  result  in  a  history  of  frequently  recurring  obstinate 
hemorrhages  from  the  slightest  of  causes. 

Hemorrhage  due  to  persistent  jaundice,  almost  invariably  follows 
gallstone  operations,  and  may  often  be  recognized  as  such  by  an  exami- 
nation of  the  coagulation  time  of  the  blood,  this  being  greatly  decreased. 

Hemorrhage  as  the  result  of  sepsis  appears  much  later  than  either 
of  the  two  preceding,  and  is  accompanied  by  such  marked  local  signs 
that  its  recognition  is  not  difficult. 

The  hemorrhage  spoken  of  as  concealed  or  internal  is  much  more 
difficult  to  recognize  than  any  of  the  above.  It  may  follow  any  o[)eration 
in  a  serous  cavity,  such  as  the  brain,  pleura,  or  peritoneum.  In  the 
brain  the  symptoms  are  those  characteristic  of  cerebral  compression 
(see  page  36).     In  the  peritoneal  cavity  the  symptoms  resemble  those 


698  POSTOPERATIVE    COMPLICATIONS. 

following  rupture  of  an  extrauterine  pregnancy,  viz.,  gradually  increasing 
pallor,  soft,  thready  pulse,  restlessness,  and  great  thirst.  Locally  there 
are  signs  of  irritation,  from  the  presence  of  free  blood  in  the  peritoneal 
cavity.  These  symptoms  of  peritoneal  irritation  are  rigidity  of  the  ab- 
dominal wall  gradually  becoming  quite  diffuse,  accompanied  by  tender- 
ness on  pressure,  and  a  moderate  amount  of  tympanites  (from  paresis 
of  the  intestinal  muscles).  These  symptoms  are  the  same  as  those  of  a 
beginning  peritonitis,  and  the  question  may  be  asked.  How  can  the  diag- 
nosis of  internal  hemorrhage  be  made  from  those  of  a  beginning  septic 
peritonitis?  The  answer  is,  that  if  the  hemorrhage  is  not  sufficiently 
marked  to  produce  signs  of  general  anemia,  a  differentiation  in  the  early 
hours  is  impossible.  Later  on,  i.  e.,  after  six  to  twelve  hours,  the  con- 
tinuation and  increase  in  gravity  of  the  peritoneal  symptoms,  unaccom- 
panied by  those  of  general  anemia,  indicate  septic  infection.  In  some 
cases  both  may  be  combined  and  the  symptoms  of  hemorrhage  in  the 
early  hours  be  followed  by  those  of  peritonitis  later. 

In  general  it  may  be  said  that  the  signs  of  internal  hemorrhage 
appear  soon  after  an  operation,  i.  e.,  in  the  first  six  hours,  while  those 
of  infection  occur  at  a  later  period. 

A  gradual  fall  in  blood-pressure  may  also  be  of  aid  in  distinguish- 
ing hemorrhage  from  postoperative  peritonitis.  The  diiferentiation  of 
shock  from  both  of  these  conditions  is  considered  under  postoperative 
peritonitis  and  shock  respectively. 

Hemorrhage  may  occur  after  operations  like  a  gastro- enterostomy  or 
those  on  the  rectum,  hke  hemorrhoids,  etc.  The  bleeding  may  take 
place  into  the  lumen  of  the  stomach  or  bowel  in  the  first-named  class 
of  operations  or  into  the  rectum  in  the  latter. 

The  early  recognition  of  such  cases  is  often  impossible  except  from 
the  actual  inspection  of  blood,  either  vomited  or  passed  with  a  bowel 
movement.  The  reason  for  this  is  that  such  a  passage  of  blood  may 
not  occur  until  the  patient  is  almost  exsanguinated.  The  only  manner 
in  which  to  diagnose  such  a  concealed  hemorrhage  before  either  a  bloody 
vomit  or  a  tarry  stool  occurs,  is  by  watching  for  the  ordinary  signs  of 
internal  hemorrhage.  These  are  (a)  gradual  or  rapidly  increasing 
pallor  of  the  skin  and  visible  mucous  membranes  (lips,  gums,  tongue, 
and  conjunctivas);  (b)  restlessness,  often  accompanied  by  dehrium  or 
stupor;  (c)  great  thirst;  (d)  the  pulse  becomes  soft  and  very  weak; 
(e)  rapid  fall  of  blood-pressure.  The  rate  is  not  necessarily  increased, 
since  Nature's  effort  to  check  the  hemorrhage  is  by  the  gradual  onset 
of  syncope.     When  hematemesis  or  evacuations  of  large  quantities  of 


SHOCK    AND    COLLAPSE.  699 

fresh  or  old  tarry  blood  take  place,  accompanied  by  these  signs  of  anemia, 
the  diagnosis  of  concealed  hemorrhac;e  is  not  difficult. 


SHOCK  AND  COLLAPSE. 

The  diagnosis  of  shock  as  a  comphcation  of  injuries  has  already 
been  referred  to  (see  page  525).  A  similar  condition  may  follow  an 
operation,  at  times  resulting  in  the  death  of  the  patients.  The  essential 
factor,  as  Crile  has  shown,  is  the  exhaustion  of  the  vasomotor  centers, 
resulting  in  the  blood  collecting  in  the  splanchnic  area  and  a  resultant 
fall  in  general  blood-pressure.  The  heart  is  affected  secondarily  through 
the  fall  of  blood-pressure,  causing  stagnation  in  the  great  venous  trunks, 
and  thus  interfering  with  its  action. 

Postoperative  shock  is  most  apt  to  follow  prolonged  operations,  and 
is  especially  frec|uent  after  those  upon  the  viscera  in  the  upper  half  of 
the  abdomen.  Collapse  or  syncope  may  follow  operation,  and  is  also 
due  to  a  fall  in  blood-pressure,  but  from  a  different  cause.  It  may  be  a 
sudden  paralysis  of  the  vasomotor  centers,  resulting  from  some  violent 
afferent  nerve  stimulus,  or  it  may  be  due  to  a  sudden  loss  of  blood.  The 
clinical  conditions  described  under  hemorrhage  should  not  be  called 
collapse,  since  the  vasomotor  centers  are  intact.  When,  however,  col- 
lapse following  a  severe  hemorrhage  has  persisted  for  a  considerable 
time,  it  begins  to  change  into  the  condition  of  true  shock,  as  the  vaso- 
motor centers  become  exhausted  from  their  efforts  to  maintain  the 
blood-pressure  at  the  same  level. 

The  chief  symptoms  of  postoperative  shock  are  the  same  as  those 
following  injury.  These  are  (a)  marked  pallor  and  coldness  of  the 
skin  and  visible  mucous  membranes,  accompanied  by  a  slight  tinge  of 
cyanosis;  (b)  a  small,  irregular,  and  rapid  pulse;  (c)  a  stuporous  or 
apathetic  appearance  of  the  patient. 

The  symptoms  vary  according  to  the  cause.  If  they  are  the  result 
of  a  sudden  vasomotor  nerve  paralysis,  there  is  almost  complete  arrest 
of  the  heart's  action,  marked  pallor,  dilated  pupils,  cold  sweat,  cold  often 
slightly  cyanotic  extremities,  feeble  or  absent  respiration,  and  almost 
complete  loss  of  consciousness.  If  the  collapse  is  due  to  severe  hemor- 
rhage, these  symptoms  differ  only  in  having  appeared  after  a  period 
during  wJu'ch  the  signs  of  sucli  hemorrhage,  viz.,  of  anemia,  predomi- 
nated. In  some  cases  it  is  almost  impossible  to  determine  whether  the 
condition  of  the  patient  is  due  to  hemorrhage  or  shock.  This  has 
already  been  referred  to  in  the  diagnosis  of  concealed  or  internal  hem- 
orrhage. 


yoo  POSTOPERATIVE    COMPLICATIONS. 

In  general,  shock  is  more  apt  to  follow  prolonged  operations  or  those 
upon  the  brain,  genitalia,  abdominal  viscera,  etc.  The  restlessness, 
pallor,  and  weakness  of  the  pulse  are  not  nearly  as  marked  in  shock  as 
in  hemorrhage. 

In  some  cases  it  is  very  difficult  to  distinguish  myocardial  symptoms, 
such  as  a  rapid,  weak  pulse,  from  those  of  shock. 


INFECTION  AS  A  COMPLICATION  OF  OPERATION. 

Infection,  like  hemorrhage,  may  be  recognized  either  through 
visible  local  signs  combined  with  those  of  a  more  constitutional  nature, 
or  the  latter  may  predominate  to  such  an  extent  that  the  local  signs 
become  insignificant. 

The  most  important  of  the  general  signs  which  indicate  infection 
is  usually  a  rise  of  temperature.  In  the  majority  of  patients  there  is  a 
slight  rise  of  temperature  for  the  first  twenty-four  to  thirtv-six  hours 
after  an  operation.  It  is  well  to  remember  that  in  children  this  post- 
operative aseptic  fever  is  relatively  higher  than  in  adults,  and  may  be 
accompanied,  especially  in  nervous  children,  by  an  increased  pulse-rate, 
which  would  be  alarming  under  other  circumstances. 

The  temperature  under  these  conditions  varies  greatly.  It  is  usuallv 
from  99°  to  ioi°  F.,  rarely  higher.  The  rise  takes  place  within  twelve 
hours  after  the  operation,  dropping  to  normal  a  few  hours  later.  It  is 
supposed  to  be  due  to  the  absorption  of  fibrin  ferment  from  the  wound, 
and  is  called,  for  lack  of  a  more  exact  name,  "ferment  or  aseptic  fever." 
If,  however,  the  rise  of  temperature  should  recur  upon  the  evening  of 
the  second  day  after  the  operation,  suspicion  should  be  aroused  that 
infection  has  taken  place.  This  secondary  rise  or  continuation  of  the 
immediate  postoperative  fever  will  remain  for  a  variable  period,  accord- 
ing to  the  nature  of  the  infective  lesion,  and  will  usually  be  accompa- 
nied by  local  signs  indicative  of  the  virulence  of  the  infection.  The 
various  septic  complications  of  an  operative  wound  differ  in  no  par- 
ticular from  those  following  an  injury.  It  will,  therefore,  not  be 
necessary  to  repeat  here  what  was  said  on  pages  529  to  55-].  about 
sapremia,  pyemia,  and  the  other  infective  wound  diseases.  At  times, 
however,  infection  may  occur  in  a  wound  with  very  little,  if  any,  fever, 
owing  to  the  low  grade  of  virulence  of  the  organisms. 

After  operations  Avithin  the  cranial,  pleural,  or  peritoneal  cavities 
infection  of  the  corresponding  serous  membrane  may  occur.  The 
symptoms  and  recognition  of  these  complications  rcfjuire  no  special 
mention,  since  they  dift'cr  but  little,  except  in  the  history,  from  those 


PULMONARY    COMPLICATIONS    FOLLOWING    OPERATIONS.  70I 

originating  without  such  operative  wound.  The  diagnosis  of  post- 
operative septic  peritonitis  will  be  considered  in  connection  with  that 
of  postoperative  ileus. 


PULMONARY  COMPLICATIONS  FOLLOWING  OPERATIONS. 

The  increased  frequency  of  these,  has  directed  the  attention  of  sur- 
geons not  only  to  their  early  recognition,  but  to  the  study  of  their  causes 
and  prevention.  It  is  not  within  the  province  of  this  book  to  discuss 
the  latter.  The  frequenc}^  with  which  the  various  forms  of  postopera- 
tive pulmonary  complications  occur  and  their  relative  influence  on  results 
are  well  shown  in  a  recent  pubhcation  of  Bibergeil.^  He  found  283 
pulmonary  complications,  i.  e.,  7.2  per  cent.,  in  3909  abdominal  opera- 
tions from  Korte's  cUnic. 

Of  these  815  were  operations  above  the  umbiKcus. 
2625  were  operations  below  the  umbilicus. 
469  were  operations  both  above  and  below  the  umbilicus. 

These  complications  were: 

Mortality. 

1.  Pneumonia  (lobular,  lobar,  hypostatic) ^35      i-i  per  cent. 

2.  Pulmonary  embolism 12      0.3    "      " 

3.  Pulmonary  infarcts 9    ii.o    "      " 

4.  Bronchitis 82 

5.  Pulmonary  abscess '. * 12 

6.  Dry  pleurisy 3 

7.  Pleurisy  with  effusion 16 

8.  Empyema 13 

9.  In  addition  to  these  mentioned,  among  quite  rare  pulmonary  complications 

are  gangrene  and  acute  edema. 

For  every  hundred  abdominal  operations  there  were  3.5  per  cent, 
pneumonias,  either  lobar,  lobular,  or  hypostatic.  This  corresponds  to 
the  relative  frequency  in  other  large  German  chnics.  The  frequency  of 
pulmonary  complications  is,  of  course,  greatest  in  advanced  life,  or  where 
there  has  been  a  preexisting  bronchitis,  etc. 

That  postoperative  pulmonary  complications  are  not  always  the 
result  of  a  general  anesthetic,  like  ether,  is  demonstrated  by  the  frequency 
with  which  they  occur  after  local  anesthesia. 

These  complications  are,  as  stated  above,  most  frequent  after  lap- 
arotomies, but  they  may  occur  as  a  result  of  almost  any  operation, 
such  as  operations  in  the  mouth,  herniotomies,  ligation  of  varicose 
veins,  etc.  They  are  especially  frecjucnt  after  incarcerated  or  strangu- 
lated herniie. 

'  ".Arcliiv  fiir  klinischc  Chirurgie,"  vol.  Ixxviii. 


702  POSTOPERATIVE    COMPLICATIONS. 

The  most  common  modes  of  origin  are  (a)  by  aspiration  of  mucus 
or  vomitus;  (b)  by  the  detachment,  from  the  field  of  operation,  of 
thrombi  which  are  carried  to  the  lungs;  (c)  migration  of  organisms 
through  the  diaphragm. 

The  recognition  of  these  various  forms  of  pulmonary  comph  cations 
usually  presents  no  difficulties,  since  t]ieir  physical  and  general  signs 
differ  but  Utile  from  those  observed  in  non-operated  cases. 

The  lobular  and  hypostatic  forms  of  pneumonia  occur  far  more 
frequently  than  does  the  lobar  or  croupous  variety.  The  latter  affects 
the  right  lower  lobe  oftener  than  any  other. 

Lobular  and  lobar  pneumonia,  pulmonary  edema,  pleuritis,  and 
bronchitis  belong  to  the  complications  which  occur  within  the  first 
week  after  an  operation.  Pulmonary  infarcts,  embolism,  abscess, 
gangrene,  empyema,  and  hypostatic  pneumonia  usually  occur  at  a 
later  period.  In  a  few  cases  pulmonary  edema  immediately  followed 
the  administration  of  the  anesthetic.  One  of  the  most  distressing  of 
these  comphcations  is  pulmonary  embolism.  This  may  occur  at  such 
a  late  period,  e.  g.,  when  the  patient  is  getting  up,  that  all  thought  of 
any  complication  has  been  dismissed.  A  thrombus  becomes  detached, 
apparently  without  cause,  from  a  vein  in  the  vicim'ty  of  the  field  of 
operation,  and  is  swept  through  the  right  heart  into  the  pulmonary 
artery.  It  lodges  in  one  of  the  primary  bifurcations  of  the  latter  vessel 
(Fig.  476),  and  gives  rise  to  most  serious  symptoms  and  often  causes  death. 

Some  of  the  emboh  may  not  occlude  the  vessel,  but  float  to  the 
periphery  of  the  lung  and  cause  subpleural  patches  of  embolic  lobular 
pneumonia.  In  40  out  of  66  cases  of  pulmonar}^  embolism  collected 
by  Lotheissen  (quoted  by  Gebele^)  the  origin  of  the  thrombus  was  in 
the  veins  of  the  leg;   the  next  most  frequent  seat  was  the  pelvic  veins. 

The  recognition  of  the  more  serious  form  of  pulmonary  embolism 
is  important.  The  symptoms  usually  appear  quite  suddenly  at  a  time 
when  least  expected.  There  is  great  dyspnea,  accompanied  by  cyanosis 
and  shallow  rapid  respirations.  The  pulse  becomes  rapid  and  almost 
imperceptible,  and  death  may  ensue  within  a  few  minutes.  In  cases 
in  which  one  recovers  from  this  condition,  the  above  symptoms  grad- 
ually diminish  in  severity.     The  physical  signs  are  practically  nil. 


CARDIAC  COMPLICATIONS. 

A  patient  with  a  normal  heart  very  rarely  develops  postoperative 
cardiac  comphcations.     The  effect  of  the  anesthetic  is  a  transient  one^ 

'  Gebele:  "Beitrage  zur  klin.  Chir.,"  vol.  xlv. 


niBs^mmBtmmtt 


Fig.  476. — Section  of  Lung  Showing  Ramifications  of  Pulmonary  Artery  and 

Lodgment  of  an  Embolus  in  One  of  the  Points  of  Bifurcation  of  the  Vessel. 

This  is  condition  found  at  autopsy  in  cases  of  pulmonary  embolism.     (See  text.) 


HEPATIC    COMPLICATIONS.  703 

as  a  rule,  leaving  no  trace  after  the  patient  has  recovered  consciousness. 
Even  under  pathologic  conditions,  it  has  been  found  that  the  anes- 
thetics most  frequently  given,  ether  and  chloroform,  have  no  ill  effects 
in  the  majority  of  cases  of  valvular  lesions.  It  is  only  in  cases  of  myo- 
carditis that  postoperative  complications  are  hable  to  follow.  In  these 
death  may  occur  as  a  result  of  the  myocarditis,  in  from  one  to  several 
days  after  the  operation,  the  severity  of  which  has  been  increased 
by  the  operation.  Under  the  latter  conditions,  in  elderly  patients  one 
not  infrequently  notices  marked  irregularity  in  the  rhythm  and  volume 
of  the  pulse  following  an  operation.  In  general  the  signs  of  such  a 
myocarditis  are  an  irregular,  weak,  and  rapid  pulse  with  feeble  heart 
tones  and  evidences  of  cardiac  dilatation. 


HEPATIC  COMPLICATIONS. 

1.  Icterus. — This  may  occur  from  a  number  of  different  causes, 
for  example: 

(a)  It  may  be  a  symptom  of  an  acute  gastro-enteritis,  occurring 
as  a  result  of  the  toxic  effects  of  the  anesthetic  upon  the  digestive 
tract. 

(&)  It  has  been  described  as  a  direct  result  of  the  toxic  action  of 
chloroform  upon  the  blood.     This  is  very  rare,  if  it  ever  occurs. 

(c)  It  may  be  a  symptom  of  one  of  the  postoperative  complications 
to  be  described,  as  cholemia  or  acid  intoxication. 

(d)  Postoperative  obstruction  of  the  common  duct  by  a  gallstone, 
which  has  either  been  overlooked  during  an  operation  for  gallstones, 
or  has  passed  down  into  the  common  bile-duct  from  the  seat  of  forma- 
tion of  the  calculus  in  the  intrahepatic  bile-ducts. 

The  diagnosis  of  the  cause  of  the  jaundice  in  a  given  case  can  only 
be  mad€  by  a  careful  study  of  the  accompanying  symptoms. 

2.  Acid  Intoxication. — This  condition  is  placed  under  the  head 
of  hepatic  comphcations  because  in  a  number  of  cases,  in  which  the 
Hver  has  been  examined  microscopically,  acute  fatty  degeneration  in 
some  cases  ^  and  necrotic  changes  in  the  parenchyma  in  others  ^  have 
been  found. 

This  complication  has  been  given  various  names,  such  as  cholemia, 
acidosis,  acetonemia,  and  acid  intoxication.  The  last-named  term 
seems  the  most  appropriate  for  the  present,  although  the  condition  is 
one  of  a  toxemia  due  to  hepatic  insufticicncy.     It  may  be  the  result 

^  Bevan  and  Favill:  "Jour.  Amer.  Med.  Assoc,"  Sept.,  1905. 
2  Eisendrath:  "Jour.  Amer.  Med.  Assoc,"  Nov.,  1901. 


704  POSTOPERATIVE    COMPLICATIONS. 

of  a  number  of  toxic  agents,  viz.,  anesthetics  (especially  chloroform)^ 
poisons,  infective  microorganisms,  and  pregnancy.  These  alTect  the 
secreting  cells  of  the  liver,  and  prevent  their  normal  function.  Acetone 
and  diacetic  and  oxybutyric  acids  are  found  in  both  the  blood  and  urine. 
They  are,  however,  to  be  regarded  as  by-products,  and  not  as  the  essen- 
tial causes. 

They  are  of  various  degrees.  In  the  milder  form  the  recovery  is 
rapid,  showing  as  symptoms  only  restlessness,  mild  delirium,  and 
drowsiness  after  the  anesthesia.  Be  van  and  Favill  have  collected 
30  cases,  of  which  28,  including  their  own,  were  fatal.  Twenty-three 
of  the  30  follov^ed  chloroform  anesthesia.  In  the  graver  cases  the 
symptoms  are  delirium,  vomiting,  restlessness,  convulsions,  coma, 
Cheyne-Stokes  respiration,  cyanosis,  and  icterus  in  a  variable  degree. 
The  most  characteristic  symptoms,  according  to  Brewer,^  are  a  sweetish 
odor  of  the  breath,  delirium,  and  rapidly  fatal  coma.  According  to 
Kussmaul,  to  these  symptoms  are  to  be  added  "air  hunger,"  /.  e.,  deep 
breathing  accompanied  by  a  bright  red  color  of  the  mucous  membranes. 
In  the  case  described  by  the  writer  in  1901,  the  chief  symptoms  were 
delirium,  coma,  intense  jaundice,  and  very  high  temperatures,  to  108°  F. 
These  symptoms  of  acid  intoxication  have  appeared  from  ten  to  one 
hundred  and  fifty  hours  after  operation. 


GASTRIC  COMPLICATIONS. 

The  most  frequent  gastric  comphcations  are : 

1.  Vom^iting. 

2.  Hematemesis. 

3.  Acute  dilatation  of  stomach. 

I.  Vomiting  after  operation  may  occur  at  various  periods,  and 
the  diagnosis  of  its  cause  rests  upon  three  factors: 

(a)  Length  of  time  which  has  elapsed  since  the  operation. 

(b)  Character  of  vomitus. 

(c)  Accompanying  symptoms. 

(a)  Length  of  Time  after  Oferation. — If  the  vomiting  is  due  to  the 
anesthetic,  it  usually  occurs  before  the  patient  has  become  fully  conscious, 
i.  €.,  in  the  first  twelve  to  twenty-four  hours  after  operation.  Ether  and 
chloroform  differ  somewhat  in  this  respect.  If  due  to  ether,  it  occurs 
usually  before  the  patient  regains  consciousness  and  is  l)rief  in  duration. 
It  begins  early  and  ends  early.  With  chloroform,  the  nausea  and  vom- 
iting may  begin  immediately  after  operation,  but  more  commonly  they 

^  "Annals  of  Surgery,"  vol.  xxxvi. 


GASTRIC    COMPLICATIONS.  705 

begin  late,  being  delayed  as  long  as  twenty-four  hours.  Postoperative 
chloroform  vomiting  is  quite  persistent,  often  lasting  three  to  four  days. 
If  vomiting  after  either  anesthetic  persists  longer  than  twenty-four  to 
forty-eight  hours  after  operation,  other  postoperative  comphcations  must 
be  thought  of,  and  search  made  for  symptoms  which  will  either  confirm 
the  suspicion  of  their  presence,  so  that  a  diagnosis  may  be  made,  or 
exclude  their  presence.  One  of  the  most  frequent  causes  of  prolonged 
postoperative  vomiting,  is  defective  excretion  of  urea,  and  not  infre- 
quently uremic  complications  are  overlooked  until  too  late  to  be 
remedied. 

Persistent  nausea  and  vomiting  as  symptoms  of  nephritic  complica- 
tions will  be  referred  to  again,  under  renal  complications.  Other  causes 
of  vomiting  appearing  later  than  the  ordinary  post-anesthetic  vomiting 
may  be  due  to  acute  dilatation  of  the  stomach,  postoperative  ileus,  and 
peritonitis.  The  diagnosis  can  only  be  made  in  such  cases  from  the 
character  of  the  vomitus  and  the  symptoms  characteristic  of  these  con- 
ditions. Let  it  not  be  forgotten  that  occasionally  chloroform  vomiting 
will  persist  for  a  number  of  days,  accompanied  by  violent  headache  and 
great  depression.  The  majority  of  these  cases  are  due  to  renal  compli- 
cations. Another  cause  of  late  postoperative  vomiting  is  that  of  acid 
intoxication  (see  page  704). 

Obstinate  postoperative  vomiting  has  frequently  been  observed  fol- 
lowing abdominal  operations  in  neurotic  individuals. 

(b)  Character  of  Vomitus. — The  vomitus  which  occurs  after  ether 
or  chloroform  anesthesia  consists  of  mucus,  or  mucus  mixed  with  bile. 
If  it  persists  for  some  hours  after  anesthesia,  it  may  consist  of  bile  alone. 
In  operations  about  the  mouth,  nose,  or  throat  the  vomiting  of  large 
amounts  of  blood,  /.  e.,  hematemesis,  may  be  a  complication  of  an  ab- 
dominal operation  and  is  referred  to  later.  In  acute  dilatation  of  the 
stomach,  which  will  also  be  described,  the  vomitus  is  a  brownish  sour 
hquid,  which  attracts  attention  on  account  of  the  large  c^uantities 
brought  up  with  each  effort.  The  diagnosis  of  these  conditions  can  be 
made  from  the  brownish  character  of  the  vomitus,  from  the  accompany- 
ing symptoms  of  collapse  and  the  distention  of  the  upper  abdomen. 
The  vomiting  occurring  as  a  result  of  postoperative  peritonitis  or  ileus 
will  be  described  under  three  heads. 

(c)  Accompanying  Symptoms. — The  \omiting  due  to  ether  or 
chloroform  is  seldom  accompanied  by  other  symjjtoms  than  those  of 
nausea  or  vertigo.  If  the  vomiting  due  to  one  of  these  anesthetics 
persists  for  a  number  of  days,  it  is  accompanied  by  great  mental  depres- 
sion and  anxiety,  hollow  sunken  eyes,  retracted  abdomen,  diminished 

45 


7o6  POSTOPERATIVE    COMPLICATIONS. 

excretion  of  urine,  dry  sidn,  etc.  If  vomiting  is  due  to  other  causes, 
such  as  postoperative  nephritis,  ileus,  peritonitis,  acid  intoxication,  or 
acute  gastric  dilatation,  the  symptoms  are  those  described  under  the 
respective  heads  in  this  chapter. 

2.  Postoperative  Hematemesis. — Reference  has  already  been 
made  under  the  head  of  "hemorrhage"  to  the  vomiting  of  blood,  occur- 
ring as  the  result  of  an  improperly  performed  gastro-enterostomy. 
One  of  the  first  to  call  attention  to  this  condition  was  von  Eiselsberg, 
in  1899.  He  reported  a  number  of  cases  in  which  it  followed  ligation 
of  the  omentum.  Since  this  time,  a  number  of  others  have  directed 
attention  to  this  postoperative  complication.  It  has  been  found  to 
follow  a  variety  of  abdominal  operations,  even  on  organs  Hke  the  appen- 
dix. The  etiology  of  the  condition  is  still  a  matter  of  dispute.  The 
vomiting  of  blood  begins  within  the  first  twenty-four  hours  after  the 
operation,  there  usually  being  an  interval  between  the  vomiting  which 
is  due  to  the  anesthetic  and  that  of  the  hematemesis.  Usually  an 
ounce  of  intensely  acid  blood  is  vomited  at  frequent  intervals.  The 
general  condition  is  similar  to  that  of  an  intense  toxemia,  with  rapid, 
small  pulse,  and  cold,  moist  skin.  This  condition  is  followed  by  a 
rapidly  progressing  collapse. 

The  diagnosis  presents  no  difficulty,  especially  if  the  black  blood 
vomited  at  frequent  intervals  is  accompanied  by  the  symptoms  of 
toxemia  mentioned  above.  The  only  condition  with  which  it  could 
possibly  be  confused,  is  acute  dilatation  of  the  stomach.  In  this,  the 
vomitus  is  thin  and  brownish  and  the  symptoms  of  collapse  appear 
much  more  rapidly.  The  enormous  swelling  of  the  upper  abdomen, 
with  displacement  of  the  lower  viscera  and  interference  with  respira- 
tion, are  also  important  diagnostic  signs  of  acute  dilatation. 

3.  Acute  Gastric  Dilatation. — ^This  condition  was  formerly  con- 
sidered to  be  a  very  rare  complication,  but  more  recent  observation 
has  shown  it  to  occur  comparatively  frequently.  This  later  view  is 
the  result  of  closer  observation  and  earlier  diagnosis.  The  generally 
accepted  theory  of  etiology  is  that  it  is  the  result  of  a  paralysis  of  the 
muscles  of  the  stomach  wall,  either  of  central  or  local  origin,  and  may 
follow  any  abdominal  operation,  especially  those  upon  the  gallbladder 
and  kidney. 

The  earhest  and  most  common  symptom  is  nausea  and  vomiting. 
This  may  begin  soon  after  recovery  from  the  anesthesia,  increasing 
in  severity  in  proportion  to  the  degree  of  dilatation.  In  other  cases 
it  may  not  begin  until  the  second  or  third  day  following  the  opera- 
tion. 


POSTOPERATIVE    ILEUS.  707 

The  vomiting  can  be  distinguished  from  the  ordinary  postoperative 
vomiting  by  the  gradual  increase  in  the  quantity  of  fluid.  Enormous 
quantities  of  thin,  broAvnish,  sour  fluid  are  vomited.  The  emesis  is 
accompanied  by  symptoms  of  collapse.  The  upper  half  of  the  abdomen 
is  at  the  same  time  much  distended  and  dull  on  percussion,  thus  differ- 
entiating it  from  postoperative  ileus,  where  it  is  tympanitic.  The 
temperature  is  either  normal  or  subnormal,  the  pulse  increased  in  fre- 
quency, and  the  urine  either  greatly  diminished  or  there  is  complete 
suppression.  Through  the  stomach-tube,  an  excessive  quantity  of 
brovmish  fluid  escapes.  The  change  in  contour  of  the  upper  half  of 
the  abdomen,  and  the  decreased  area  of  dullness  after  every  expulsion 
of  vomitus,  show  that  this  fluid  is  not  free  in  the  peritoneal  cavity. 
Many  of  the  milder  cases  recover  spontaneously,  although  the  majority 
end  fatally  unless  speedy  relief  is  given. 


POSTOPERATIVE  ILEUS. 

This  subject  has  attracted  considerable  attention.  Various  divis- 
ions have  been  suggested.  The  one  hitherto  accepted  by  the  majority 
of  surgeons  has  been  that  of  Mikulicz  into: 

(a)  Mechanical. 

(b)  Dynamic. 

Finney^  has  recently  suggested  what  seems  to  be  a  better  classifi- 
cation; his  division  is  as  follows: 

(a)  ]Mechanical. 

(b)  Septic. 

(c)  Dynamic. 

While  the  distinction  is  very  often  impossible,  the  diagnostic  fea- 
tures are  generally  as  follows: 

Mechanical  ileus  is  characterized  by  later  onset,  visible  peristalsis, 
and  severe  colicky  abdominal  pains.  The  abdominal  distention  is 
asymmetrical,  and  at  first  there  is  no  change  in  the  pulse  or  tempera- 
ture. Later  the  condition  is  characterized  by  persistent  vomiting  and 
constipation. 

Septic  ileus  is  often  masked  by  the  general  signs  of  septicemia, 
thus  differing  in  its  clinical  aspect  from  that  of  mechanical  ileus. 

A  dynamic  ileus  develops  as  the  result  of  a  paralysis  of  the  intestinal 
muscles,  with  few  of  the  signs  of  obstruction  and  none  of  the  signs  of 
septicemia.  The  diihculty  of  differentiating  an  acute  ileus  from  an 
acute  peritonitis  is  apparent,  and  the  later  the  case  is  seen,  the  more 

^  "Annals  of  Surgery,"  June,  1906. 


705  POSTOPERATIVE    COMPLICATIONS. 

difficult  does  this  differentiation  become,  for  advanced  cases  of  obstruc- 
tion are  almost  always  complicated  by  peritonitis.  In  both  conditions 
the  leukocytes  are  increased,  and  in  both  the  opsonic  content  of  the  blood 
is  very  high.  The  method  of  estimating  this  opsonic  content  of  blood 
has  recently  been  studied  by  Simon  and  Lemar.^  This  will  be  de- 
scribed on  page  716.  In  favor  of  the  diagnosis  of  obstruction  are  a 
rapid,  feeble  pulse;  ashy,  pinched  countenance;  rapid  distention  of  the 
abdomen,  which  is  not  board-like;  increased  peristalsis;  earlv  and 
severe  vomiting,  soon  becoming  fecal;  severe,  cramp-Mke  pain  referred 
to  the  umbihcal  region,  and  absence  of  fever. 

In  some  cases  of  postoperative  obstruction  no  symptoms  appear 
until  weeks  or  months  after  the  operation.  The  symptoms  are  usuallv 
due  to  bands  or  adhesions.  The  diagnosis  in  these  cases  presents 
no  difficulty.  The  symptoms  of  obstruction  appear  in  a  patient  Avho 
has  previously  been  subjected  to  an  abdominal  operation. 

There  are  other  cases  in  which  adhesions  following  an  operation 
result  in  incomplete  obstruction.  In  this  class,  especially  frequent 
after  appendiceal  operations,  the  patients  present  a  variety  of  symp- 
toms. The  patient  may  complain  simply  of  colicky  pains,  accompanied 
by  more  or  less  abdominal  distention  and  constipation.  In  other 
cases  there  is  the  history  of  cohcky  pains,  accompanied  by  nausea 
and  vomiting,  recurring  at  irregular  intervals.  A  form  of  postopera- 
tive ileus  of  the  mechanical  type,  to  be  especially  mentioned,  is  stran- 
gulation of  a  loop  of  intestine  in  a  postoperative  hernial  opening.  This 
may  occur  months  or  years  subsequent  to  an  operation. 


POSTOPERATIVE  PERITONITIS. 

The  occurrence  of  peritonitis  is  comparatively  infrequent,  as  a 
postoperative  complication  at  the  present  time.  The  symptoms  and 
diagnosis  do  not  differ  in  any  respect  from  those  occurring  in  peri- 
tonitis complicating  disease  or  injury  of  any  of  the  abdominal  viscera, 
that  is,  not  following  operation. 

The  chief  diagnostic  points  are:  (a)  Cohcky  pains,  gradually  increas- 
ing in  severity;  (b)  uniform  muscular  rigidity,  and  tenderness  on  press- 
ure over  the  abdomen;  ic)  rapidly  increasing  distention;  (d)  gradu- 
ally rising  pulse-rate,  reaching  140  to  160,  or  even  higher  at  the  end 
of  twenty-four  hours;  (e)  absolute  constipation,  regardless  of  cathar- 
tics or  enemas;  (/)  sunken  eyes;  anxious  expression,  subnormal  tem- 
perature, general  cyanosis,  cold  and  clammy  extremities,  dry,  coated 

^  "Johns  Hopkins  Hosj).  Bull.,"  Jan.,  1906, 


RENAL    COMPLICATIONS.  709 

tongue,  diminished  secretion  of  urine,  vomiting  and  hiccough,  often 
persistent. 

The  symptoms  which  should  attract  the  most  attention  are  the 
rapidly  increasing  pulse-rate,  the  condition  of  the  abdomen,  and  the 
complete  obstipation,  neither  feces  nor  flatus  being  passed. 

RENAL  COMPLICATIONS. 

Both  ether  and  chloroform  have  an  irritant  effect  upon  the  normal 
Iddneys.  A  large  number  of  observers  have  found  that  in  about  25 
per  cent,  of  all  cases  the  administration  of  either  of  these  anesthetics 
is  followed  by  the  appearance  of  albumin  and  of  hyaline  and  granular 
casts  in  the  urine.  This  condiiton  of  renal  irritation  lasts  only  from 
one  to  four  days,  as  a  rule,  and  does  not  give  rise  to  any  .postoperative 
symptoms. 

Cases,  however,  have  been  reported  by  Frankel  and  others  where 
prolonged  (two  to  three  hours)  administration  of  chloroform  has  been 
followed  in  eight  to  ten  days  by  death.  In  such  cases  the  chloroform 
caused  marked  fatty  degeneration  of  the  heart  muscle,  as  well  as  of 
the  hepatic  and  renal  parenchyma. 

It  has  also  been  found  ^  that  during  the  administration  of  ether  to 
animals,  the  excretion  of  nitrogenous  substances  is  practically  abolished. 

The  question  which  is  of  direct  interest  in  respect  to  postoperative 
renal  complications  is.  Do  ether  and  chloroform  have  any  ill  effects 
upon  the  diseased  kidney?  There  is  some  difference  of  opinion  in 
regard  to  this  question.  There  are  some  surgeons  who  believe  that 
it  is  perfectly  safe  to  give  ether  to  nephritic  patients.  The  majority, 
however,  believe  that  the  administration  of  chloroform,  as  a  rule,  is  not 
followed  by  renal  complications  in  those  previously  suffering  from  such 
disease.  Ether  may,  on  the  other  hand,  be  given  to  a  large  percentage 
of  patients  suffering  from  nephritis  of  the  more  chronic  type  and  not 
be  followed  by  any  mild  or  graver  signs  of  irritation. 

In  a  certain  percentage  of  cases  there  is  indisputable  chnical  evi- 
dence that  various  forms  of  renal  complications  ma}'  occur  after  opera- 
tion.    This  often  takes  place  when  least  expected. 

The  various  clinical  forms  of  such  complications  are: 

I.  Mild  uremic  symptoms,  such  as  ia)  nausea  and  vomiting  (pro- 
longed many  days  after  this  common  postoperatix'e  symptom  should 
have  ceased);  (b)  headache;  (c)  diminished  (|uantily  of  urine,  con- 
taining variable  amounts  of  albumin  and  casts,  and  decrease  in  urea 
percentage. 

'  "British  Medical  Journal,"  Sept.  9,  1905. 


7IO  POSTOPERATIVE    COMPLICATIONS. 

2.  Grave  uremic  symptoms — such  as  convulsions,  restlessness, 
delirium,  and  coma.  The  secretion  of  urine  may  be  practically  abolished 
or  it  may  contain  the  various  constituents  so  characteristic  of  uremia 
under  non-operative  conditions.  These  may  be  blood,  hyaline,  gran- 
ular, and  epithelial  casts,  renal  epithelium,  large  quantities  of  albumin, 
and  a  very  small  amount  of  urea. 

Postoperative  renal  complications  usually  appear  within  twenty- 
four  to  forty-eight  hours  after  the  anesthesia.  They  may  occur  in  the 
following  classes  of  patients: 

1.  As  an  acute  exacerbation  of  a  latent  nephritis,  which  had  not 
been  recognized  before  operation. 

2.  As  an  acute  nephritis  developing  in  a  patient  who  had  been 
previously  known  to  have  a  chronic  nephritis,  either  latent  or  active. 

3.  As  a  reflex  anuria  of  one  kidney,  following  operations  upon  the 
opposite,  especially  nephrectomy  or  nephrotomy. 

The  diagnosis  in  all  of  these  classes  of  cases  can  only  be  made: 
(a)  by  excluding  other  conditions  which  might  give  rise  to  postopera- 
tive nausea,  vomiting,  dehrium,  etc.;  (b)  by  the  previous  history  of 
the  case  as  to  urinary  findings;  (c)  by  the  examination  of  the  urine 
both  quantitatively  and  quahtatively. 


CIRCULATORY  COMPLICATIONS. 

Thrombosis  and  Embolism. — Postoperative  comphcations,  at 
times  of  the  gravest  character,  may  be  the  result  of  a  thrombosis  of  an 
adjacent  vein,  which  has  occurred  either  prior  to  such  operation  or  has 
developed  subsequently  to  it.  In  the  former  condition  we  speak  of 
a  preoperative  and  in  the  latter  of  a  postoperative  thrombosis.  If 
the  phlebitis  is  of  a  non -suppurative  type,  the  condition  may  give  rise 
to  local  signs,  such  as  pain  and  sweUing,  or  it  may  cause  any  of 
the  forms  of  embohc  pulmonary  complications  spoken  of  on  page  702, 
viz.,  infarcts,  pneumonia,  emboHsm,  and  pleuritis.  If  the  phlebitis 
is  of  the  septic  or  suppurative  type  the  clinical  picture  is  more  hke 
that  of  a  septicopyemia  with  the  formation  of  metastatic  foci  of  septic 
infarction  or  embolism. 

The  non-suppurative  type  of  postoperative  thrombosis  is  compara- 
tively frequent.  Cordier^  in  a  recent  paper  states  that  it  occurs  in  about 
2  per  cent,  of  all  abdominal  operations.  It  is  most  common  after 
appendectomy,  herniotomy,  salpingectomy,  oophorectomy,  and  hyster- 
ectomy.    It  occurs  even  when  the  primary  condition  has  been  an  asep- 

'  "  Jour.  Amer.  Med.  Assoc,"  1905,  p.  1792. 


MISCELLANEOUS    POSTOPERATIVE    COMPLICATIONS.  71I 

tic  one.  Gangrene  of  the  affected  limb  has  never  occurred.  In  the 
majority  of  cases  either  the  right  or  left  femoral  or  saphenous  veins 
are  affected  or  the  veins  of  both  sides. 

In  a  number  of  cases  the  mesenteric  or  pelvic  veins  or  those  of  the 
abdominal  wall  are  affected. 

Clinically  these  cases  of  phlebitis  appear  in  one  of  two  forms: 

1.  A  variable  time  after  operation,  usually  from  the  seventh  to  the 
fourteenth  day,  the  patient  may  suddenly  show  the  signs  of  pulmonary 
embohsm  described  on  page  702,  viz.,  dyspnea,  cyanosis,  rapid  pulse, 
etc.  These  are  the  cases  in  which  either  a  diagnosis  of  phlebitis  was 
not  made,  on  account  of  the  depth  of  the  vein  involved,  or  the  clinical 
picture  of  a  phlebitis  was  not  recognized. 

2.  The  phlebitis  with  resultant  thrombosis  appears  about  the  tenth 
to  fourteenth  day.  It  causes  pain  referred  to  the  location  of  the  sapheni 
or  other  veins  involved.  Accompanying  the  pain  there  is  tenderness 
over  the  course  of  the  vein,  and  the  latter  can  be  felt  (if  the  saphenous 
is  involved)  as  a  firm,  tender  cord. 

If  the  femorals  are  involved,  there  is  usually  quite  marked  swelling 
of  the  entire  limb,  the  edema  being  of  a  firm  character,  and  the  skin 
glossy  and  pale  (the  phlegmasia  alba  dolens  of  former  days).  At 
times  all  of  the  superficial  veins  are  quite  prominent  and  thrombosed. 
.  The  diagnosis  in  these  cases  of  postoperative  thrombosis  is  usually 
not  difficult,  if  veins  like  the  sapheni  or  femorals  are  involved.  In 
the  other  veins  a  diagnosis  before  the  occurrence  of  embolic  symptoms 
is  impossible. 


MISCELLANEOUS  POSTOPERATIVE  COMPLICATIONS. 
Postoperative  Eruptions. — (a)  Surgical  Scarlatina. — This  sub- 
ject has  been  thoroughly  reviewed  by  Dr.  Alice  Hamilton.^  It  may 
occur  'after  almost  any  operation,  in  both  adults  and  children.  It 
does  not  differ  clinically  from  ordinary  scarlatina  except  in  the  follow- 
ing particulars: 

1.  It  is  especially  apt  to  attack  adults. 

2.  The  period  of  incubation  is  shorter  than  that  of  ordinary  scar- 
latina. 

3.  The  eruption  begins  at  the  wound  or  in  some  other  unusual  place. 

4.  The  throat  symptoms  are  either  mild  or  absent. 

5.  Desquamation  occurs  at  an  earher  period. 

In  the  majority  of  cases  reported  in  the  literature  as  surgical  scar- 
'  "American  Journal  of  Med.  Sciences,"  1904. 


712  POSTOPERATIVE    COMPLICATIONS. 

latina,  the  eruption  was  either  due  to  sepsis  or  to  erysipelas.  The 
latter  is  especially  apt  to  be  puzzling  to  differentiate,  if  it  begins  in  the 
throat  as  an  angina. 

(b)  Septic  Rashes. — This  greatly  resembles  a  surgical  scarlatina, 
but  can  be  differentiated  from  it  by  the  accompanying  symptoms  of 
septicemia.  The  eruption  is  usually  a  diffuse  erythema,  is  accompanied 
b)^  a  marked  rise  in  temperature,  rapid  pulse,  restlessness,  etc.  It 
usually  lasts  only  a  few  days.  In  children  it  appears  even  in  mild 
cases  of  sepsis,  and  frequently  the  eruption  is  the  only  symptom  present. 
There  are  usually  no  changes  in  the  wound  even  in  the  graver  cases. 
In  these  cases  the  symptoms  of  septicemia  (page  537)  accompany  the 
eruption. 

The  following  are  some  of  the  points  which  may  help  in  distin- 
guishing a  septic  from  a  scarlet  fever  rash: 

1.  The  premonitory  febrile  symptoms  are  usually  absent,  the  rash 
being  the  first  thing  noticed  in  most  cases. 

2.  The  distribution  of  the  rash  is  irregular;  it  appears  often  simul- 
taneously all  over  the  body,  and  not,  as  in  scarlet  fever,  on  the  neck 
and  face  first. 

3.  There  are  no  throat  symptoms,  except  in  those  cases  where  the 
wound  is  in  the  throat. 

4.  The  pyrexia  is  high  and  of  the  septic  type,  with  often  marked 
intermissions. 

(c)  Drug  Eruptions  and  Poisoning. — These  may  either  be  local, 
as  the  result  of  the  action  on  the  skin  of  the  field  of  operation,  or  there 
may  be  more  generalized  eruption.  They  are  frequent  after  the  use 
of  bichlorid  of  mercury,  carbolic  or  sahcyhc  acids,  or  any  preparation 
containing  iodin. 

The  locahzed  eruption  is  either  a  fine  pustular  one,  or  there  are 
all  the  signs  of  an  acute  dermatitis.  The  more  generalized  eruptions 
are  usually  of  the  erythematous  type,  often  accompanied  by  intense 
pruritus. 

The  occurrence  of  postoperative  symptoms  of  iodoform,  carbolic 
acid,  or  of  bichlorid  poisoning  are  so  rare  at  the  present  time  that  they 
require  no  special  mention,  being  fully  described  in  the  text-books  on 
therapeutics  and  materia  medica. 


DIABETIC  COMPLICATIONS. 

These  arc  of  the  utmost  importance,  and  may  be  of  various  forms. 
I.  A  latent  diabetes  mav  be  aroused  into  activit^^ 


POSTOPERATIVE    PAROTITIS — STATUS    THYMICUS.  713 

2.  A  previously  existing  diabetes  may  be  greatly  intensified  and 
cause  most  serious  complications.  Glycosuria  has  been  found  to  occur 
in  normal  individuals  after  operations.  The  sugar  is,  however,  transi- 
tory and  is  so  slight  in  amount  as  to  have  no  clinical  significance. 
The  usual  forms  in  which  postoperative  diabetic  complications  appear, 
are  (a)  as  a  gangrene  of  the  edges  of  the  wound  or  of  a  limb  with  early 
evidences  of  marked  sepsis;  (b)  as  a  coma  accompanied  by  pulmonary 
edema  and  resulting  fatally  within  a  few  days  after  the  operation; 
(c)  as  a  marked  glycosuria,  which  gradually  subsides  without  giving 
rise  to  any  general  symptoms. 

The  development  of  these  diabetic  complications  must  always  be 
borne  in  mfind,  not  only  in  those  whose  urine  was  known  to  contain 
a  trace  or  a  larger  quantity  of  sugar  before  the  operation,  but  in  every 
patient  above  middle  age.  A  preoperative  urinary  examination  must 
always  include  the  test  of  sugar.  The  diagnosis  of  a  diabetic  coma 
must  be  made  by  excluding  other  causes  for  coma  or  gangrene  and 
finding  sugar  in  the  urine. 


POSTOPERATIVE  PAROTITIS. 

This  occurs  most  frequently  after  abdominal  operations,  and  is 
often  described  as  a  cceliac  parotitis.  It  may  also  appear  as  a  compli- 
cation of  inflammatory  affections  of  the  abdominal  viscera. 

The  parotid  gland  of  one  or  both  sides  is  almost  invariably  involved. 
The  inflammation  may  be  (a)  of  a  simple  type,  like  that  occurring  in 
the  epidemic  form  of  parotitis  (mumps);  (b)  abscess  formation  may 
take  place;  (c)  gangrene  of  the  parenchyma  may  occur.  The  diag- 
nosis is  not  difficult.  The  appearance  after  an  abdominal  operation 
of  a  swelling,  just  in  front  of  and  below  the  ear,  accom.panied  by  tender- 
ness and  fever,  is  quite  characteristic.  If  suppuration  or  gangrene 
occur,  the  local  signs  are  correspondingly  more  marked. 


STATUS  THYMICUS. 

This  peculiar  complication-  of  anesthesia  has  been  recognized  for 
some  time.  After  the  administration  of  chloroform,  death  has  suddenly 
occurred,  accompanied  by  symptoms  of  cardiac  and  respiratory  paralysis. 
In  the  autopsies  on  these  cases,  usually  children,  a  general  hyperplasia 
of  the  lymphatic  structures  has  been  found.  The  thymus  gland  is 
markedly  enlarged  and  from  this  finding  the  condition  first  received 
its  name. 


714  POSTOPERATIVE   COMPLICATIONS. 

ACUTE  THYROIDISM. 

This  is  a  complication  occurring  after  thyroidectomy.  The  symp- 
toms are  a  great  rise  in  temperature  (103°  to  108°  F.),  high  pulse-rate, 
face  flushed,  restlessness,  and  at  times  delirium  and  coma. 

The  condition  may  be  only  a  transitory  one,  or  it  may  result 
fatally. 

POSTOPERATIVE  HYSTERIA. 
This  requires  no  special  description.    The  diagnosis  of  the  various 
forms,  in  which  this  protean  affection  may  appear,  does  not  differ  in 
any  manner  from  the  recognition  of  hysteria  occurring  under  other 
circumstances  than  as  a  postoperative  condition. 


CHAPTER  VIII. 

METHODS  OF  EXAMINATION. 

Examination  of  the  Blood  in  Surgical  Cases. 

The  methods  of  chnical  examination  of  the  blood  which  are  of 
surgical  interest  are: 

1 .  Counting  the  red  and  white  corpuscles. 

2.  Estimation  of  the  percentage  of  hemoglobin. 

3.  Examination  for  the  plasmodium  malariae. 

4.  The  differential  leukocyte-count. 

5.  The  determination  of  the  opsonic  index. 

The  technic  of  the  first  three  of  these  is  so  fully  discussed  in  the 
special  books  upon  the  blood  and  diagnostic  methods  that  it  may  be 
omitted  here. 


DIFFERENTIAL  LEUKOCYTE-COUNT. 
Attention  has  been  recently  called  by  Gibson  ^  to  the  value  of  the 
differential  leukocyte-count  in  surgical  cases,  especially  those  due  to 
infection.     Normally  the  percentage  of  each  variety  of  leukocyte,  as 
given  by  Cabot, Mn  the  blood  of  healthy  adults  is: 

J  Small  lymphocytes 20         to  30  per  cent. 

\  Large  lymphocytes , . .    4         to    8        " 

(b)  Polynuclear  neutrophiles 62         to  70        " 

(c)  Eosinophiles 0.5      to    4       " 

(J)  Mast-cells 0.025  ^°    °-9    " 

Sahli  estimates  the  number  of  polynuclear  neutrophiles  at  70  to  72  per 
cent.  Sondern's  average  for  polynuclear  neutrophiles  in  the  normal  blood 
is  68  per  cent.     Gibson  has  adopted  75  per  cent,  as  a  working  average. 

The  method  of  estimating  the  different  kinds  of  leukocytes  is  readily 
accomplished  by  staining  a  film  of  dried  blood  by  the  Ehrlich,  Wright,^ 
or  Zolhkoffer''  stains.  The  apphcation  of  this  differential  leukocyte- 
count  to  surgical  diagnosis  will  be  referred  to  on  page  725. 

'  "Annals  of  Surgery,"  April,  1906.  ^  Cabot:  "Clinical  Examination  of  Blood." 

^  Cabot:  " Clinical  Examination  of  Blood."  ^  Sahli:  "Diagnostic  Methods." 


•i6 


METHODS    OF    EXAMIXATIOX. 


OPSONINS  AND  THE  OPSONIC  INDEX. 

The  school  ot\- ^letchnikoff  beheves  that  the  leukocyte  is  the  only 
element  of  the  blood  actively  concerned  in  the  phagocvtosis  of  micro- 


^     9  f   9   e 


Fig.  477. — Thoma-Zeiss  Blood-cootting  Apparatus. 
A,  Melangeur;   B,  coundng-chamber,  seen  from  above;   C,  profile  of" counting-chamber:   D,  microscopic  pic- 
mre  of  a  portion  of  ruled  field  with  "blood-cells;    £,  white  counter. 


organisms.  It  attributes  everything  to  the  white  blood-corpuscle,  and 
does  not  consider  that  the  blood-fluid  takes  any  active  part  in  the  phe- 
nomenon. 

In  the  early  part  of  1903,  Wright  and  Douglas,  of  St.  AIary"s  Hospital, 
London,   approached   the  problem  of  phagocytosis.     They  separated 


OPSONINS    AND   THE    OPSONIC    INDEX,  717 

the  corpuscular  from  the  fluid  elements  of  the  blood.  That  is  to  say, 
they  obtained  leukocytes  suspended  in  a  neutral  medium  instead  of  in 
the  blood-plasma,  and  the  blood-plasma  (or  blood-serum)  free  from 
leukocytes  or  erythrocytes.  They  prepared  also  an  emulsion  of  staphy- 
lococci in  normal  salt  solution,  and  found  that,  if  they  brought  together 
only  the  leukocytes  and  the  staphylococci,  practically  no  phagocytosis 
occurred,  but  that  the  addition  of  blood-plasma  (or  blood-serum)  to 
the  leukocytes  and  the  staphylococci  effected  some  change,  so  that 
phagocytosis  did  occur.  The  obvious  deduction  was  that  the  leu- 
kocyte by  itself  was  impotent,  and  further  that  the  blood-plasma  con- 
tained some  substance  which  was  essential  to  the  attainment  of  phago- 
cytosis. 

Using  ingenious  methods  of  their  own  devising,  they  investigated  the 
blood-plasma  in  order  to  determine  the  characters  of  this  phagocytic 
element,  and  the  following  are  the  most  important  of  their  conclusions: 

1.  The  substance,  so  essential  to  phagocytosis,  does  not  act  upon 
the  leukocytes  (as  a  stimulant  to  the  leukocytes,  for  example),  but  it 
combines  with  the  microorganisms  and  prepares  them  for  phagocytosis; 
hence  the  name  opsonin,  from  opsono,  I  cater  for,  I  prepare  victuals 
for.  The  conception  of  their  mode  of  action  is  that  the  opsonins  are 
carried  in  the  lymph  to  the  nest  of  microbes  which  are  responsible  for 
the  morbid  process ;  that  they  chemically  unite  with  the  microorganisms, 
and  that  then,  and  not  until  then,  the  leukocytes  have  the  power  of 
enveloping  and  destroying  these  microorganisms.  Thus  it  follows 
that  the  amount  of  phagocytosis  which  is  observed  is  a  measure  of  the 
quantity  of  opsonins  present  in  any  particular  plasma,  and  does  not 
represent  the  vital  activity  of  the  leukocytes. 

2.  The  opsonins  in  a  normal  serum  are  almost  completely  destroyed 
by  heating  for  ten  minutes  at  60°  C. 

3.  The  opsonins  have  been  shown  to  be  distinct  from  the  bacter- 
iolysins,  the  agglutinins,  and  the  antitoxins. 

Moreover,  as  shown  by  Bulloch  and  Mestern,  the  opsonins  have  a 
high  degree  of  specificity.  For  example,  the  blood  of  a  person  may 
contain  half  the  normal  quantity  of  opsonins  necessary  to  combat  a 
tuberculous  infection  such  as'  tuberculous  cystitis,  and  yet  contain  a 
normal  amount  of  opsonins  that  have  to  do  with  an  invasion  of  staphy- 
lococci, such  as  causes  furunculosis. 

Wright  and  Douglas  have  shown  b}-  a  striking  experiment  how 
invariable  a  factor  the  leukocyte  really  is.  They  obtained  leukocytes 
both  from  an  immunized  patient  and  also  from  a  normal  individual. 
To  a  specimen  of  each  of  these  they  added  some  normal  serum,  and 


7l8  METHODS    OF   EXAMINATION. 

also  some  staphylococci,  and  allowed  phagocytosis  to  take  place.  They 
then  found  that  in  the  presence  of  normal  serum  the  leukocytes  of  the 
immunized  patient  took  up  just  as  many  staphylococci  as  the  normal 
leukocytes  in  the  presence  of  the  same  normal  serum.  They  next  took 
two  portions  of  a  suspension  of  normal  leukocytes  to  which  had  been 
added  some  staphylococci,  and  mixed  with  one  of  these  portions  some 
serum  from  the  immunized  patient,  and  with  the  other  some  normal 
serum,  and  allowed  phagocytosis  to  take  place.  They  then  found  that 
the  leukocytes,  to  which  had  been  added  the  serum  from  the  immunized 
patient,  took  up  about  one-half  as  many  staphylococci  as  did  the  leu- 
kocytes to  which  the  normal  serum  had  been  added.  This  affords 
striking  testimony  that  the  leukocyte  is  an  indifferent  or  a  constant 
factor  in  the  phenomenon  of  phagocytosis.  The  amount  of  phagocytosis 
observed,  therefore,  represents  the  quantity  of  opsonins  present  in  the 
blood.  So  far  as  we  can  tell  at  present,  the  plasma  has  nothing  to  do 
with  the  "quahty"  of  the  leukocytes. 

Technic. — If  we  wish  to  measure  the  quantity  of  opsonins  present 
in  the  blood  of  a  man  suffering  from  furunculosis,  which  is  almost 
always  due  to  the  staphylococcus  pyogenes,  we  require : 

1.  A  drop  or  two  of  blood  from  the  patient,  and  a  drop  or  two  from 
a  normal  person,  from  each  of  which  we  can  easily  obtain  sufficient 
serum  for  our  estimation. 

2.  An  emulsion  of  staphylococci  in  salt  solution. 

3.  Leukocytes  washed  free  from  their  plasma. 

We  draw  up  in  a  capillary  pipet  equal  quantities  of  the  patient's 
serum,  the  staphylococcus  emulsion,  and  the  leukocytes;  thoroughly 
mix  all  three,  and  having  sealed  the  mixture  in  the  capillary  tube,  place 
it  in  an  incubator  at  37°  C. 

With  a  second  capillary  pipet  we  again  carry  out  precisely  the  same 
operations,  except  that  instead  of  the  patient's  serum  we  use  normal 
serum.  This  is  incubated  for  the  same  length  of  time.  An  ordinary 
blood-film  is  made  from  each  tube  at  the  expiration  of  the  fifteen  minutes' 
incubation.  These  films  are  appropriately  stained,  and  then  examined 
microscopically  with  an  oil-immersion  lens.  .  Numerous  leukocytes  are 
seen,  in  the  protoplasm  of  which  lie  few  or  many  staphylococci.  The 
number  of  staphylococci,  taken  up  by  say  40  leukocytes,  is  counted. 
Let  us  say  that  in  the  film  prepared  with  the  patient's  serum  we  count 
80  staphylococci  in  the  40  leukocytes.  The  average  per  leukocyte  is 
then  f-jj  or  2.  This  figure  is  known  as  the  "phagocytic  index"  of 
the  leukocyte.  We  then  count  the  number  of  staphylococci  taken  up 
by  the  40  leukocytes  in  the  film  prepared  with  the  normal  scrum;  let 


OPSONINS    AND   THE    OPSONIC   INDEX.  719 

US  say  we  count  i6o  staphylococci;  if  we  divide -j'V^-  we  get  the  "normal 
phagocytic  index"  for  this  particular  experiment,  namely,  4. 

In  each  of  these  preparations  the  leukocytes  and  the  emulsion  of 
staphylococci  are  constant  factors;  the  only  variable  factor  is  the  blood- 
serum. 

The  amount  of  phagocytosis  depends  upon  the  quantity  of  opsonins 
present.  It  follows,  therefore,  that  the  comparison  between  the  two 
phagocytic  indices  above  recorded,  is  a  comparison  between  the  quantity 
of  opsonins  present  in  the  blood-serum  of  a  diseased  person  and  in  that 
of  a  normal  person.  The  actual  ratio  in  this  case  is  2  :  4  or  0.5  :  i ;  the 
latter  figure  is  the  normal  "opsonic  index,"  and  0.5  is  the  abnormal 
opsonic  index  of  a  patient  who  is  the  subject  of  a  staphylococcus  infec- 
tion, namely,  furunculosis. 

When  we  say  that  a  patient  has  an  opsonic  index  of  0.5  to  staphy- 
lococcus, we  mean  that  his  blood-plasma  contains  but  half  the  normal 
quantity  of  those  opsonins  which  are  essential  to  combating  a  staphy- 
lococcal infection  successfully.  Moreover,  it  seems  probable  that  this 
deficiency  was  antecedent  to  the  infection  or,  in  other  words,  it  has  made 
the  infection  possible. 

The  Opsonic  Index :  Bacterial  Infections. — Certain  generah- 
zations  have  emerged  from  the  investigation  of  numerous  cases. 

1.  If  the  bacterial  infection  be  strictly  locahzed,  the  opsonic  index 
of  the  blood,  as  concerns  the  particular  microbe  causing  the  infection, 
is  below  normal.  For  example,  the  blood  of  a  patient  who  is  suffering 
from  furunculosis  will  probably  show  an  opsonic  index  of  about  0.6  to 
the  infecting  microorganisms,  that  is,  to  the  staphylococcus  pyogenes; 
or,  again,  the  blood  of  a  patient  who  is  suffering  from  tuberculous  glands 
in  the  neck  will  probably  show  an  opsonic  index  of  about  0.7  to  the 
tubercle  bacillus.  In  each  case,  the  patient's  blood  is  compared  with 
the  blood  of  a  normal  man. 

2.  The  second  generahzation  has  to  do  with  those  infections  which 
are  not  strictly  locahzed.  In  such  cases  the  opsonic  index  will  be  found 
high  at  one  time  and  low  at  another;  that  is,  the  opsonic  index  in  sys- 
temic infections  tends  to  fluctuate  from  high  to  low.  This  character- 
istic is  well  shown  in  cases  of  acute  pulmonary  tuberculosis. 

These  two  generalizations  are  of  primary  importance  both  as  con- 
cerns the  diagnosis  and  the  treatment  of  bacterial  infections. 


720  METHODS    OF    EXAMINATION. 

LEUKOPENIA,  LEUKOCYTOSIS,  AND  HYPERLEUKOCYTOSIS, 

By  the  term  leukopenia  is  understood  a  state  of  the  blood  in  which 
there  is  a  decrease  in  the  number  of  white  corpuscles.  Leukocytosis 
means  an  increase  of  white  corpuscles.  For  clinical  purposes  it  is 
advisable  to  consider  10,000  as  the  extreme  limit  of  ordinary  normal 
leukocytosis.  The  term  hyperleukocytosis  is  used  by  some  to  indicate 
any  counts  in  excess  of  10,000.  By  the  majority  of  surgeons,  the  term 
leukocytosis  is  used  to  indicate  any  increase  of  white  corpuscles  above 
the  normal.  Leukocytoses  are  either  physiologic  or  pathologic.  In 
the  latter  the  polynuclear  neutrophile  cells  predominate. 

Leukocytosis  in  inflammation  is  regarded  as  an  index  of  reaction, 
rather  than  of  the  absolute  severity  of  an  infection.  As  Sondern  says, 
"Good  resistance  on  the  part  of  the  body  will  produce  pronounced 
leukocytosis,  even  in  slight  infections.  Poor  resistance  produces  little 
leukocytosis  in  slight  and  none  at  all  in  severe  infections." 

Physiologic  Leukocytosis. 
A  normal  increase  may  occur  under  the  following  conditions: 

1.  During  digestion. 

2.  After  exertion  or  a  cold  bath. 

3.  During  pregnancy,  parturition,  and  the  puerperium. 

4.  In  new-born  children  (up  to  30,000). 

The  leukocytosis  of  digestion  begins  about  one  hour  after  a  meal, 
and  reaches  its  maximum  (a  30  to  40  per  cent,  increase)  in  about  three 
to  four  hours  (Rieder).  Considering  the  comparatively  shght  digestion 
leukocytosis,  any  great  degree  of  pathologic  leukocytosis  can  be  recog- 
nized, even  during  digestion. 

Leukocytosis  occurs  after  the  administration  of  ether  and  after 
operations  as  a  transitory  condition. 

Pathologic  Leukocytosis, 

In  the  Infectious  Diseases. — Pneumonia. — A  leukocytosis  reach- 
ing as  high  as  50,000  to  60,000  is  quite,  common  in  this  disease. 
The  leukocytosis  is  composed  of  polynuclear  neutrophiles.  A  normal 
leukocyte-count  with  a  relative  increase  of  the  polynuclear  neutro- 
philes, indicates  a  severe  infection  and  reduced  resistance. 

Typhoid  Fever. — In  this  condition  a  normal  leukocytosis  or  even 
a  leukopenia  is  the  rule.  This  is  of  great  aid  in  distinguishing 
typhoid  from  pyogenic  infections. 

Complications  which  cause  a  rapid  increase  in  the  number  of  white 


LEUKOPENIA,    LEUKOCYTOSIS,    AND    HYPERLEUKOCYTOSIS.  7 21 

corpuscles  are  perforation,  suppuration,  cystitis,  parotitis,  pulmonary 
complications,  nephritis,  thrombosis,  and  cholecystitis. 

Acute  Articular  Rheumatism. — In  uncomplicated  cases  of  this 
disease  there  is  usually  a  slight  polynuclear  neutrophilic  leukocytosis 
(about  15,000),  which  persists  as  long  as  there  is  fever  and  exudation. 

Meningitis. — In  suppurative  meningitis  there  is  always  a  marked 
leukocytosis,  while  in  tuberculous  meningitis  the  leukocyte-count  may 
be  normal  or  up  to  20,000.  Absence  of  leukocytosis  points  to  tubercu- 
losis, but  its  presence  does  not  exclude  it. 

Scarlet  Fever.— In  this  condition  the  blood  shows  a  leukocytosis 
with  high  eosinophiles,  which  serves  to  distinguish  this  eruptive  fever 
from  septic  rashes,  etc.,  in  which  the  polynuclear  neutrophiles  predomi- 
nate and  the  eosinophiles  are  relatively  low. 

Erysipelas  has  a  very  high  leukocytosis  of  the  typical  septic  variety, 
namely,  a  great  increase  in  the  neutrophiles. 

Septicemia  is  characterized  by  a  rapid  development  of  severe  anemia. 
There  is  usually  a  marked  leukocytosis,  except  in  some  very  mild  cases, 
and  in  severe,  rapidly  fatal  cases.  Blood-cultures  may  contain  the  causal 
organism. 

Local  abscess  formation  usually  shows  a  leukocytosis. 

Illustrations  of  such  a  localized  pus  formation  are  a  felon,  gum 
boil,  external  cutaneous  abscess,  genital  abscess,  parotic  abscess,  sub- 
phrenic abscess,  infections  in  the  neck,  etc. 

Special  Varieties  of  Abscess  Formation. — Appendicitis. — In  tliis 
condition  the  leukocyte- count  affords  valuable  aid  for  us  both  as  to  the 
diagnosis  of  the  condition,  as  well  as  to  the  stage  of  the  pathologic  process. 
The  count  should  be  made  at  regular  intervals,  say  every  hour  or  two, 
in  all  cases,  and  compared  with  the  symptoms  and  general  condition  of 
the  patient. 

The  foUomng  are  general  conclusions  from  actual  cases,  according  to 
Cabot : 

1.  There  are  no  changes  in  the  red  cells,  except  the  anemia  of  chronic 
cases. 

2.  Coagulation  slow,  but  the  fibrin  is  always  increased  in  pus  cases.- 

3.  As  in  all  infections,  the  "very  mild  and  very  septic  cases  show 
no  leukocytosis. 

4.  Catarrhal  appendicitis  is  rarely  accompanied  by  leukocytosis. 
An  increase  from  12,000  to  14,000  is  a  rare  exception. 

5.  An  increasing  leukocytosis  is  an  evidence  of  a  spreading  process. 
It  should  be  closely  watched  and  never  disregarded.  This  is  of  far 
more  significance  than'the  actual  niunber  of  cells. 

46  / 


722  ■       METHODS    OF   EXAMINATION. 

6.  A  low  count,  8,000  to  11,000,  means  one  of  several  things: 
{a)  A  mild  case. 

(b)  A  very  severe  case  in  which  the  resistance  of  the  organism  is 
diminished. 

(c)  An  abscess  thoroughly  walled  off. 

After  the  abscess  has  become  walled  off  the  count  usually  remains 
stationary  or  shghtly  decreases.  If  the  count  rapidly  increases  after 
such  a  condition,  it  means  that  the  abscess  has  ruptured  into  the  perito- 
neal cavity.  Such  a  rupture  may  not,  however,  be  accompanied  by  an 
increase,  but  sometimes  by  a  rapid  fall  of  the  leukocyte-count. 

7.  In  the  majority  of  cases  the  abscess  is  not  completely  walled  off, 
and  a  moderately  fluctuating  leukocytosis  is  found. 

When  the  leukocytosis  increases  slowly  and  steadily,  the  case  is 
increasing  in  severity,  as  a  rule. 

When  a  leukocytosis  of  18,000  to  25,000  is  maintained,  it  means 
a  localized  large  abscess. 

8.  Size  of  leukocytosis: 

(a)  Catarrhal,  usually  below  12,000. 

(b)  Acute  diffuse  appendicitis  without  pus,  11,000  to  22,000. 

(c)  Gangrenous  appendicitis,  usually  20,000  or  more. 

(d)  When  pus  distends  the  appendix  the  count  is  high,  20,000  or 
over. 

When  an  acute  perforation  occurs  into  the  free  peritoneal  cavity, 
the  leukocytosis  may  fall  temporarily;  if  a  reaction  on  the  part  of  the 
body  takes  place,  a  rapid  increase  follows;  if  no  reaction  takes  place, 
there  is  no  increase. 

Differential  Diagnosis. — The  leukocytosis  of  appendicitis  will  difl'er- 
entiate  the  following  conditions : 

(a)  Intestinal  colic  and  the  crises  of  locomotor  ataxia. 

(b)  Impaction  of  feces. 

(c)  Gallstone  colic  and  renal  colic,  if  no  infection  is  present. 

(d)  Ovarian  and  pelvic  neuralgic  pains. 

(e)  Floating  kidney. 

(/)  Extrauterine  pregnancy — this  does  cause  a  leukocytosis  at  times, 
however. 

Acute  and  Chronic  Salpingitis  and  Pelvic  Peritonitis. — These 
cause  the  same  changes  as  found  in  appendicitis,  and  the  blood-count 
is  of  value  only  in  distinguishing  them  from  non-septic  conditions. 

Infection  of  the  Gallbladder  and  Bile-passages. — Exactly  the 
same  may  be  said  of  these  as  of  pelvic  infection  and  appendicitis.  The 
blood  is  only  of  value  to  estabhsh  the  fact  of  infection  and  pus  forma- 
tion, but  is  of  little  value  in  differentiating  it  from  other  abscesses. 


LEUKOPENIA,    LEUKOCYTOSIS,    AND   HYPERLEUKOCYTOSIS.  723 

Osteomyelitis  has  a  high  leukocytosis  which  is  extremely  valuable 
in  differentiating  it  at  an  early  stage  from  rheumatism  or  the  prodromes 
of  infective  disease,  especially  smallpox. 

Infections  of  the  Serous  Membranes. — Pleural,  Pericardial,  and 
Peritoneal. — This  is  almost  always  accompanied  by  a  leukocytosis. 
The  degree  of  leukocyte  increase  is  extremely  variable,  and  varies 
from  normal  to  40,000,  and  even  higher.  It  is  not  always  possible  to 
differentiate  the  serous  and  dry  inflammations  from  the  suppurative, 
as  the  latter  may  not  have  a  higher  leukocytosis  than  other  varieties. 

The  leukocyte  count  is,  however,  valuable  in  the  following  condi- 
tions : 

{a)  To  differentiate  peritonitis  from  (i)  obstruction  (non-malignant), 
(2)  mahgnant  disease,  (3)  hysteria,  malingering,  etc.  A  leukocytosis 
speaks  in  favor  of  an  inflammatory  process. 

(b)  From  tuberculous  infection,  which  has  no  leukocytosis. 

Gastro-intestinal  Tract. — Gastric  ulcer  causes  an  increasing 
anemia  with  a  moderate  leukocytosis.  Of  diagnostic  value  excepting 
in  complications. 

(a)  Perforation,  a  rapid  rise  in  the  leukocyte-count  is  usual. 

{b)  Hemorrhage,  often  an  increase  of  leukocytosis.  In  chronic 
hemorrhagic  cases  the  picture  may  simulate  a  pernicious  anemia. 

Duodenal  Ulcer. — Same  as  in  ulcer  of  stomach  proper. 

Acute  Gastro-intestinal  Affections . — A  fairly  well  marked  leukocytosis 
is  the  rule. 

Chronic  Digestive  Disturbances. — As  a  rule,  no  leukocytosis  and  no 
digestion  leukocytosis. 

Intestinal  Obstruction. — -According  to  Bloodgood,  the  leukocyte- 
count  here  is  valuable.  Within  a  few  hours  the  leukocytes,  rise  rapidl}'. 
If  obstruction  is  partial,  the  counts  are  between  14,000  and  16,000; 
if  complete,  usually  20,000  or  more.  The  higher  the  count  and  the 
shorter  the  duration,  the  greater  the  probabiHty  of  gangrene.  If  the 
count  shows  20,000  within  the  first  twenty-four  hours,  the  chances  are 
that  gangrene  is  present.  On  the  second  day  the  count  does  not  change 
much.  Then  if  gangrene  or  peritonitis  occurs  the  count  begins  to 
fall;  otherwise  the  count  remains  high  until  the  fourth  or  fifth  dav,  when 
the  leukocytes  graduaUy  fall,  whatever  the  condition  of  the  abdomen. 
If  after  three  days  of  obstruction  the  count  is  still  over  20,000  the  prog- 
nosis is  good.  If  the  count  is  below  15,000  the  probability  is  that 
gangrene,  peritonitis,  or  fatal  auto-intoxication  has  occurred. 

Surgical  Conditions  of  the  Liver. — The  coagulation  time  of  the 
blood  is  reduced  in  all  conditions  affecting  the  function  of  the  liver. 


724  METHODS    OF   EXAMINATION. 

This  is  especially  true  if  jaundice  is  present,  when  the  hemorrhage 
from  an  operative  procedure  may  be  uncontrollable.  Usually  the  cap- 
illary vessels  are  the  worst  ones. 

Gallstones,  when  no  infection  is  present,  cause  little  or  no  change. 
A  sKght  leukocytosis  is  sometimes  found.  During  a  colic  this  may  be 
slightly  increased,  but,  as  a  rule,  not  to  be  compared  with  the  leuko- 
cytosis of  infectious  processes.  All  infectious  processes  of  the  liver 
and  bile-passages  cause  a  marked  leukocytosis;  for  example,  cholangitis, 
cholecystitis,  abscess,  thrombosis,  and  infections  of  the  blood-vessels. 
This  is  valuable  in  differentiating  them  from  typhoid,  grippe,  etc., 
which  may  simulate  these  conditions. 

Diseases  of  the  Pancreas. — Acute  pancreatitis  and  hemorrhagic 
pancreatitis  show  a  fair  increase  in  the  leukocyte-count,  which  will  help 
to  distinguish  them  from  the  ordinary  pains  of  indigestion,  etc. 
Chronic  pancreatitis  shows  no  such  change,  a  low  percentage  of 
hemoglobin  being  the  only  help  in  a  diagnostic  way  that  may  be 
present. 

Urinary  System. — Infections  cause  a  leukocytosis.  This  is  the 
only  distinguishing  feature,  and  aids  in  determining,  for  instance, 
when  pus  is  present  in  calculous  obstruction,  and  helps  fix  indica- 
tions for  an  operation. 

The  same  holds  true  in  all  kidney  and  bladder  affections.  The 
determination  of  the  functional  capacity  of  the  kidneys  by  means  of  the 
freezing-point  of  the  blood  will  be  described  elsewhere  (see  page  747)- 

Nervous  System. — The  blood  examination  is  of  little  value  in 
diagnosing  diseases  of  the  nervous  system  directly,  as  few  characteristic 
conditions  are  produced. 

Injuries,  infections,  and  all  suppurations  increase  the  number 
of  leukocytes,  so  that  they  help  to  estabhsh  the  presence  of  an  obscure 
abscess,  for  instance,  or  differentiate  it  from  a  tumor.  The  leukocyte-, 
count  is  of  value  in  detecting  malignancy  and  hysteria  in  many  cases. 

Malignant  Disease. — Blood  examinations  in  malignant  tumors 
sometimes  afford  substantial  aid  in  locating  and  determining  the  rapidity 
of  growth  and  the  degree  of  malignancy,  the  presence  of  ulceration  and 
secondary  infection,  as  well  as  of  repeated  internal  hemorrhages,  when 
carefully  considered  together  with  the  symptoms. 

The  blood  as  a  whole  shows  the  picture  of  a  secondary  anemia, 
that  is,  the  reduction  in  the  hemoglobin,  and  the  blood-ceUs  are  in  about 
the  same  proportion. 

Occasionally  the  blood-destroying  power  or  malignancy  of  the  tumor 
is  so  great  that  the  picture  of  a  pernicious  anemia  is  produced. 


THE    VALUE    OF   THE    DIFFERENTIAL   LEUKOCYTE-COUNT.  725 

In  most  cases  the  coagulation  time  is  normal  or  increased.  When 
sloughing  is  present,  it  becomes  more  rapid.  When  an  inflammatory 
reaction  occurs  around  the  tumor,  the  fibrin  may  be  greatly  increased. 
The  red  cells  are  usually  smaller  in  size,  pale,  and  are  easily  destroyed. 

The  hemoglobin  in  cancer  cases  will  average  50  per  cent,  or  lower. 

The  color  index  is  almost  invariably  below  i. 

The  leukocyte  changes  in  cancer  are  important  and  depend  on  the 
following  conditions: 

I.  On  the  position  of  the  growth. 

(a)  When  the  tumor  is  situated  in  the  esophagus  or  cardia,  the 
leukocytes  may  be  diminished.  It  is  in  this  situation  that  the  pernicious 
type  of  anemia  is  frequent.  When  the  leukocytes  are  increased,  it  is 
fair  to  assume  the  presence  of  these  growths  in  other  locations,  or  that 
extensive  sloughing  is  taking  place. 

(b)  Cancer  of  the  uterus  and  of  the  stomach,  especially  if  hemorrhages 
are  taking  place,  show  a  high  leukocyte-count. 

(c)  Malignant  tumors  of  the  kidney,  thyroid,  and  pancreas  almost 
always  cause  a  high  leukocytosis. 

II.  Size.  Everything  else  being  equal,  tumors  of  the  parenchy- 
matous organs  and  viscera  cause  greater  leukocytosis  than  the  slower 
growing  epitheliomatous  and  scirrhus  varieties.  For  example,  cancers 
of  the  skin,  lip,  scirrhus  of  the  breast,  etc.,  cause  a  lov/  leukocyte-count, 
while  tumors  of  the  liver  and  kidney  produce  very  large  ones,  as  these 
tumors,  as  a  rule,  grow  to  be  of  large  size. 

III.  Cancer  of  the  bones  and  blood-forming  organs  may  give  a 
blood-picture  depending  on  the  blood-function  of  these  organs.  For 
instance,  large  numbers  of  myelocytes,  eosinophiles,  and  intermediate 
cells  may  be  present,  in  some  respects  simulating  leukemia,  so  offering 
valuable  aid  in  locating  metastasis  in  bones,  etc. 

Sarcoma. — The  blood  in  this  condition  is  of  about  the  same  impor- 
tance as  in  carcinoma,  with  the  exception  that  the  changes,  as  a  rule,  are 
greater. 


THE  VALUE  OF  THE  DIFFERENTIAL  LEUKOCYTE-COUNT. 

The  paper  of  Gibson^  previously  referred  to  (page  715)  is  a  valuable 
contribution  to  the  value  of  this  diagnostic  method.  He  believes  that 
the  real  value  of  the  polynuclear  count  lies  in  "//«e  relative  dis  pro  portion 
of  the  polynuclear  percentage  to  the  total  leukocytosis.'''  He  believes 
that  ''with  a  moderate  rise  of  the  total  leukocytosis  there  should  be,  in 

'  "Annals  of  Surgery,"  April,  1906. 


720  METHODS    OF    EX.UIIXATIOX. 

favorable  cases,  a  moderate  rise  of  the  polynuclear  cells  only,  showing 
that  the  infection  is  localized  and  absorption  is  limited.  On  the  other 
hand,  if  there  is  only  a  moderate  leukocytosis  with  a  notable  increase 
in  the  polynuclear  cells,  it  indicates  almost  unquestionably  that  there 
is  either  a  severer  form  of  lesion  or  less  resistance  to  absorption,  or  that 
both  conditions  exist."     His  conclusions  will  be  quoted  in  full.^ 

The  differential  leukocyte-count  is  of  value  chiefly  in  indicating 
fairly  consistently  (i)  the  existence  of  suppuration  or  gangrene,  as 
evidenced  by  an  increase  of  the  polynuclear  cells  disproportionately 
high  as  compared  to  the  total  leukocytosis. 

(2)  The  greater  the  disproportion,  the  surer  are  the  findings,  and  in 
extreme  disproportions  the  method  has  proved  itself  practically  infallible. 

(3)  As  the  relative  disproportion  between  the  leukocytosis  and  the 
percentage  of  polynuclear  cells  is  of  so  much  more  value  than  the  findings 
based  on  a  leukocyte-count  alone,  this  latter  method  should  be  abandoned 
in  favor  of  the  newer  and  more  reliable  procedure. 

(4)  The  negative  findings,  showing  no  relative  increase  or  even 
an  actual  decrease  of  the  proportion  of  the  polynuclear  cells,  while 
of  less  value,  shows  with  rare  exceptions  the  absence  of  the  severer  forms 
of  inflammation. 

(5)  In  its-  practical  applications,  the  method  is  of  more  frequent 
value  in  the  interpretation  of  the  severity  of  the  lesions  of  appendicitis 
and  their  sequela. 

Value  of  the  Ordinary  Leukocyte-count  in  Differential  Diag- 
nosis.— I.  When  we  are  dealing  with  an  obscure,  deep-seated  disease 
when  hemorrhage  can  be  excluded,  the  presence  of  a  persistent 
leukocytosis  suggests  suppuration  or  malignant  disease,  rather  than 
tuberculosis  or  syphilis,  for  example,  and  excludes  any  simple  func- 
tional or  hysterical  affection.  The  absence  of  leukocytosis,  however, 
does  not  exclude  malignant  disease,  though  it  makes  suppuration  very 
unhkely. 

II.  Between  malignant  disease  and  suppuration,  if  the  other  signs 
and  symptoms  do  not  decide,  there  may  be  nothing  in  the  blood  to 
decide.  In  decided  pyemia  we  may  get  pyogenic  cocci  in  the  blood  by 
culture,  but  a  negative  result  would  not  exclude  a  suppurating  focus. 
The  reaction  of  iodophilia  may  help  to  decide  the  presence  of  pus,  also 
the  increase  of  fibrin  in  the  blood  speaks  for  the  presence  of  pus. 

III.  Between  malignant  disease  and  hemorrhage,  a  marked  anemia 
favors  hemorrhage,  as  the  anemia  of  cancer  is  slow  to  develop.  The 
leukocytes  give  no  special  aid. 

'  For  further  details,  the  reader  is  referred  to  the  original  article. 


THE    VALUE    OF    THE    DIFFERENTIAL   LEUKOCYTE-COUXT.  727 

IV.  Between  cancer  and  ulcer  of  the  stomach,  if  there  has  been  no 
recent  hemorrhage,  leukocytosis  favors  cancer,  but  its  absence  is  of  no 
weight  either  way.  In  cancer  the  hemoglobin  steadily  decreases, 
while  in  ulcer  it  fluctuates — increasing  between  hemorrhages,  and 
dropping  immediately  after  one. 

The  presence  of  a  digestion  leukocytosis  speaks  for  ulcer,  but  if  any 
degree  of  catarrh  and  glandular  degeneration  is  present  it  would  also 
be  absent  in  ulcer. 

V.  Between  cancer  of  the  liver  and  bile-ducts,  on  the  one  hand,  and 
simple  gallstone  coHc  or  obstruction,  on  the  other,  the  presence  of  a 
leukocytosis  favors  cancer,  and  we  must  bear  in  mind  that  gallstones 
with  cholangitis  may  raise  the  leukocyte-count  as  much  or  more  than 
in  cancer.  Simple  cysts  or  echinococcus  cysts  cause  no  leukocytosis, 
nor  does  syphiHs  of  the  Hver. 

VI.  The  appearance  in  the  blood  of  large  numbers  of  eosinophiles, 
myelocytes,  and  nucleated  rods  will  arouse  the  suspicion  of  metastasis 
in  the  bones. 

VII.  If  the  leukocytosis  disappears  with  the  removal  of  the  growth 
and  then  reappears,  we  may  look  for  recurrence  of  the  growth. 

VIII.  A  steadily  increasing  leukocytosis  in  a  case  of  malignant 
disease  points  to  a  rapidly  growing  tumor  or  the  occurrence  of 
metastasis. 

IX.  Between  malignant  disease  and  pernicious  anemia,  the  diagnosis 
will  rest  on  the  following  points : 

ALiLiGNAKT  Disease.  Pernicious  Anemia. 

Color  index  and  volume  index.  .Low — less  than  i.  Usually  above  i. 

Leukocytosis Usually  increased.  Diminished. 

Lymphoc}'tes Relatively  decreased.  Increase  in   active   num- 

ber. 

Average  size  of  red  cell Usually  below  normal,  7.5.  Often      increased,      and 

great  variation  in 
size. 

Nucleated  red  cells If    present,    the    normoblast       Normoblasts  the  minority 

type    predominates.  — megaloblasts     fre- 

quent. 

X.  Between  a  malignant  "and  a  benign  tumor,  the  presence  of  a 
leukocytosis  will  speak  against  its  being  benign. 

XL  When  we  suspect  a  tumor  and  no  actual  increase  in  the  whole 
count  is  present,  the  increase  of  the  polymorphonuclear  variety  will 
have  the  same  significance  as  a  leukocytosis. 

Tuherculosis  in  a  general  way  may  be  stated  to  cause  a  gradual  loss 
of  hemoglobin  and  red  cells,  producing  the  typical  secondary  anemia. 


728  METHODS    OP   EXAMINATION. 

The  leukocytes  are  usually  not  Increased  when  secondary  infection  is 
absent,  and  this  is  valuable  in  diagnoses. 

There  are  many  exceptions  to  this  rule,  however,  such  as: 

Meningeal  tuberculosis — leukocytosis  7,000  to  30,000. 

Bone  tuberculosis — often  a  shght  increase. 

Genital  tuberculosis — a  leukocytosis  is  rather  the  rule. 

Syphilis. — The  blood-findings  offer  httle  information  to  the  surgeon 
for  diagnostic  purposes — except  possibly  the  fact  that  the  increasing 
lymphocytosis  would  indicate  a  late  stage  and  its  non-contagious  stage. 


PERNICIOUS  ANEMIA. 
{a)  Red  blood-cells  1,200,000  per  cu.  mm. 

(b)  White  blood-cells  much  below  7,500  per  cu.  mm. 

(c)  Hemoglobin  variable — relatively  increased,  very  often  color  index 
high. 

{d)  Deformity  in  shape  and  size  of  red  blood-corpuscles  frequent. 

{e)   Red  cells  stain  irregularly  (polychromatophiha). 

(/)   Megaloblasts  more  numerous  than  normoblasts. 

{g)  Lymphocytosis. 

Must  be  distinguished  surgically  from: 

1.  Pernicious  type  of  anemia  of  mahgnant  tumors.  In  some  cases 
absolutely  impossible  from  the  blood  alone,  but  usually  a  microphitic 
increase  is  present  with  a  low  color  index. 

2.  From  anemia  produced  by  tuberculosis  and  very  chronic  suppu- 
ration. 

3.  Acute  suppuration  will  show  a  leukocytosis,  low  hemoglobin 
amounts,  low  color  index. 

4.  Chronic  hemorrhage — as  from  piles,  stomach  ulcers,  etc.  Not 
always  possible,  but  picture  of  blood  will  approach  more  nearly  that 
of  a  secondarv  anemia. 


LEUKEMIA. 

Characteristics  of  blood: 
I.  Myeloid  leukemia. 

{a)  Red  cells  about  3,000,000 — nucleated  cells  very  numerous. 

(&)  White  cells  about  450,000,  of  which 

(c)   Myelocytes  form  about  30  per  cent. 

{d)  Every  possible  form  of  white  cell  intermediate  between  the 
ordinary  varieties  is  to  be  seen.     (Polymorphous  blood.) 


THE    ESTIMATION    OF    BLOOD-PRESSURE    IN    SURGICAL    CASES.       729 

2.  Chronic  lymphatic  leukemia. 

(a)  Red  cells  about  3,000,000  or  lower,  nucleated  cells  rare. 

(b)  White  cells  about  300,000,  of  which 

(c)  Small  lymphocytes  form  over  90  per  cent. 

(d)  Myelocytes  and  eosinophiles  are  rare. 

3.  Acute  lymphatic  leukemia. 

(a)  Red  cells  much  diminished,  nucleated  cells  rare. 

(b)  Large  forms  of  lymphocytes  predominate,  often  degenerated. 

(c)  Neutrophiles  and  eosinophiles  very  scanty. 

The  above  blood-picture  will  serve  to  distinguish  leukemia  from 
other  diseases  causing  splenic  and  glandular  enlargement,  as  well  as 
from  tumors  simulating  such  enlargements : 

1.  Hodgkin's  disease. 

2.  Tumors  of  spleen  and  vicinity  (kidney  and  retroperitoneal  lymph- 
nodes). 

3.  Enlargement  of  lymph-nodes  from  tuberculosis,  syphilis,  malig- 
nant disease. 

4.  Hydronephrosis. 

5.  Large  leukocytosis  from  any  cause. 

6.  Chronic  malaria. 

7.  Amyloid  disease. 

THE  ESTIMATION  OF  BLOOD-PRESSURE  IN  SURGICAL  CASES. 

Blood- pressure. — The  determination  of  blood-pressure  has  assumed 
such  practical  importance  that  every  surgeon  should  be  famiHar  with 
the  use  of  the  appropriate  instruments. 

Of  the  latter  there  are  a  number  of  different  lands.  The  one  which 
is  most  easily  employed  at  the  bedside  or  operating  table  is  the  Riva- 
Rocci  sphygmomanometer,  as  modified  by  Cook  and  Briggs  (see 
Fig.  16).  For  details  as  to  its  use,  the  reader  is  referred  to  special 
treatises  on  the  subject  of  blood-pressure.  Experimental  and  clinical 
observations  by  Crile,  Cushing,  Cook,  Janeway,^  and  others  have  shown 
that  the  estimation  of  blood-pressure  is  of  great  value  from  both  a 
diagnostic  and  therapeutic  standpoint  in  the  following  surgical  condi- 
tions : 

During  Surgical  Operations.— To  be  of  value  a  determination 
should  be  made  every  five  minutes,  the  pulse-rate  being  recorded  on  a 
chart.     Ether,  even  in  large  amounts,  seldom  produces  a  significant 

1  Janeway:  "Clinical  Study  of  Blood-pressure."  Cook:  "Jour.  Amer.  Med.  Assoc," 
p.  1 199,  1903. 


73°  METHODS    OF   EXAMINATION. 

fall  in  blood-pressure.  Chloroform  is  usually  accompanied  by  a 
marked  fall  in  blood-pressure  in  69  per  cent.,  and  a  moderate  fall  in 
18.9  per  cent,  of  the  cases,  according  to  Blauel. 

An  initial  rise  in  blood-pressure  follows  any  cutting  operation,  while 
the  irritation  of  large  nerve-trunks  causes  a  much  greater  reflex  rise 
of  blood-pressure. 

The  opening  of  the  peritoneal  cavity  is  at  first  followed  by  a  sharp 
rise,  but  there  is  a  subsequent  fall  in  blood-pressure  dependent  on  the 
duration  of  the  operation  and  the  amount  of  exposure  and  manipulation 
of  the  viscera. 

Blood-pressure  in  Surgical  Accidents  and  Diseases.  Hem- 
orrhage.— The  loss  of  any  considerable  volume  of  blood,  either  during 
an  operation  or  as  the  result  of  an  accident,  causes  an  immediate  fall 
in  blood-pressure.  It  is  very  difficult  to  draw  any  deductions  after  an 
accident  as  to  whether  the  low  amount  of  blood-pressure  is  the  result 
of  hemorrhage  or  shock.  This  uncertainty  is  due  to  the  fact  that  the 
acute  anemia  causes  a  considerable  degree  of  shock.  One  distinction 
is,  however,  present,  viz.,  that  if  the  bleeding  is  checked  or  ceases  spon- 
taneously, and  is  not  succeeded  by  shock,  the  blood-pressure  will  grad- 
ually rise.  This  latter  condition  is  due  to  the  fact  that  there  is  a  definite 
physiologic  tendency  for  the  blood-pressure  to  return  to  its  level. 

Collapse  and  Shock. — The  term  shock,  according  to  Crile,^  should 
be  hmited  to  the  condition  (page  526)  in  which  there  is  a  gradual  fall 
in  blood-pressure.  The  term  collapse  should  be  confined  to  those 
cases  in  which  the  essential  phenomenon  is  a  sudden  fall  of  blood-pres- 
sure, due  to  hemorrhages,  injuries  of  the  vasomotor  center,  or  cardiac 
failure.  The  lowering  of  the  blood-pressure  in  shock  is  due  to  repeated 
afferent  impulses  acting  on  the  vasomotor  center  and  causing  exhaus- 
tion of  the  latter. 

In  operations  involving  handling  or  long  exposure  of  abdominal 
viscera,  after  subcutaneous  injuries  of  the  thoracic  or  abdominal  viscera, 
or  in  peripheral  injuries  such  as  follow  a  crushing  force,  there  is  a  steady 
fall  in  blood-pressure  as  a  symptom  of  shock. 

Head  Injuries. — The  marked  rise  in  blood-pressure,  as  an  expres- 
sion of  increased  intracranial  tension  in  head  injuries  or  diseases,  has 
been  referred  to  (page  38). 

The  estimation  of  the  blood-pressure  is  of  considerable  value  in 
connection  with  all  other  general  and  focal  symptoms. 

A  low  blood-pressure,  according  to  Kocher^  and  Gushing,^  may  be 

'  "Boston  Medical  and  Surgical  Jour.,"  March  5,  1903. 

^  Nothnagel's  "Spec.  Path.  u.  Therap.,"  vol.  ix. 

^  "  Amer.  Jour,  of  the  Med.  Sciences,"  1902  and  1903. 


CYTODIAGNOSIS.  73I 

present  in  concussion  and  in  the  paralytic  stage  of  compression.  A 
marked  rise  in  blood-pressure  follows  any  lesion,  wliether  traumatic  or 
non-traumatic,  which  produces  an  increase  of  the  intracranial  pressure 
and  resultant  anemia  of  the  medulla  (page  38). 

The  writer  makes  it  a  practice  to  have  systematic  blood-pressure 
measurements  made  at  regular  intervals  (every  half  hour)  in  cases  of 
head  injuries. 

A  high  blood-pressure  is  present  in  (a)  acute  compression  of  the 
brain  from  splinters  of  a  depressed  fracture,  or  from  an  extradural  or  sub- 
dural clot;  (b)  in  fractures  of  the  base  of  the  skull;  (c)  in  cerebral 
apoplexy. 

A  high  and  rising  blood-pressure  indicates  progressive  failure  of 
circulation  in  the  medulla  and  an  increasing  hemorrhage. 

Hemorrhage  into  the  anterior  fossa  of  the  skull  has  the  least,  while 
that  into  the  posterior  fossa  has  the  most,  effect  on  general  blood- 
pressure.  Uremic  coma  is  accompanied  by  increased  blood-pressure,  so 
that  this  symptom  cannot  be  utilized  to  differentiate  uremic  from  apoplec- 
tic coma. 

Acute  Peritonitis. — The  arterial  tension  rises  in  the  early  stages 
of  acute  peritonitis,  and  this  sharp  rise  in  blood-pressure  may  be  of 
great  value  in  making  a  diagnosis  of  typhoid  perforation  and  other 
forms  of  incipient  peritonitis. 


CYTODIAGNOSIS. 

This  method  of  examination  is  of  increasing  interest  to  surgeons. 
It  consists  in  the  study  of  the  character  and  number  of  the  cellular 
constituents  of  exudates  and  transudates.  For  the  technic  of  this 
method  the  many  special  text-books  should  be  referred  to.^ 

The  conclusions  obtained  should  never  be  employed  as  the  sole 
means  of  making  a  diagnosis.  It  is  and  must  always  remain  a  single 
symptom.     Cytodiagnosis  is,  however,  of  aid  in  the  following  fluids: 

Cerebrospinal  Fluid. — In  epidemic  cerebrospinal  meningitis  the 
fluid  is  at  first  clear,  and  gradually  becomes  more  turbid.  Polynuclear 
neutrophiles  predominate  in  all  stages,  but  in  some  the  lymphocytes 
are  in  the  majority. 

In  tuberculous  meningitis,  either  mononuclears  or  polynuclears  pre- 
dominate, usually  the  former.  All  forms  of  purulent  meningitis  of  trau- 
matic or  metastatic  origin  show  microorganisms  and  typical  pus  cells. 

'  Sahli:  "Diagnostic  Methods." 


732  .         METHODS    OF    EXAMINATION. 

In  tetanus  and  in  cerebral  tumors  there  are  no  cells  in  the  cerebro- 
spinal fluid. 

These  findings  enable  one  to  make  a  differential  diagnosis  of  acute 
spinal  meningitis  from  tetanus,  or  from  the  cerebral  symptoms  of  a 
tumor,  or  from  the  acute  infectious  diseases. 

Pleural  Fluids. — i.  A  predominance  of  lymphocytes  means  a 
tuberculous  effusion. 

2.  A  predominance  of  polynu  clear  neutrophiles  means  an  effusion 
of  an  acute  infectious  origin. 

3.  A  large  number  of  endothehal  cells,  occurring  especially  in  sheets 
or  plaques,  means  a  mechanical  effusion  or  transudate. 

4.  In  neoplasms  of  the  pleura.  Free  tumor  cells  are  often  found 
in  bunches.  The  cells  are  difficult  to  distinguish  from  leukocytes  and 
endothehum,  because  both  of  the  latter  are  also  present  in  the  exudate 
of  a  neoplasm.     Karyokinesis  speaks  for  a  neoplasm. 

There  have  been  too  few  observations  of  joint,  peritoneal,  or  pericar- 
dial fluids  to  draw  anv  conclusions. 


EXAMINATION  OF  THE   SPUTUM,  STOMACH  CONTENTS.  URINE,  AND 

FECES. 

The  importance  of  a  thorough  examination  of  these  secretions  and 
excretions  cannot  be  too  strongly  emphasized.  They  are  of  the  greatest 
value  from  a  diagnostic  standpoint. 

The  results  have  been  discussed  in  connection  with  the  various  in- 
juries and  surgical  diseases  in  the  preceding  chapters.  It  is  beyond  the 
scope  of  a  book  of  this  character  to  describe  the  technical  procedures. 
For  the  latter  the  reader  is  referred  to  the  many  standard  treatises  de- 
voted to  this  purpose  (Sahli,  Boston,  Simon,  von  Jaksch,  etc.). 


THE  NEWER  METHODS  OF  DIAGNOSIS  OF  RENAL  LESIONS. 
Ureteral  Catheterization  and  Examination  with  Sounds,  Etc.^ 
The  urine  from  each  kidney  can  be  collected  separately  by  means 
of  elastic  catheters  inserted  into  the  ureters.  The  tip  of  the  catheter 
should  only  extend  beyond  the  vesical  end  of  the  ureter.  If  the  catheter 
has  not  been  passed  into  the  pelvis  of  the  kidney,  urine  is  ejected  from 
the  distal  (i.  e.,  external)  portion  of  the  catheter  at  intervals,  just  as  it  is 
normally  from  the  ureteric  opening  into  the  bladder.     If  the  tip  of  the 

^  The  sections  upon    Ureteral    Catherization  and  Cystoscopy  were  written    by  Dr. 
Gustav  Kolischer,  of  Chicago. 


THE   NEWER   METHODS   OF  DIAGNOSIS   OF   RENAL   LESIONS.  733 

catheter  extends  into  the  pelvis  of  the  kidney  the  urine  drips  out  in  a 
continuous  stream.  At  times  the  insertion  of  a  ureteral  catheter  is 
followed  by  a  temporary  reflex  anuria.  The  flow  of  urine  through  the 
catheter  may  also  be  obstructed  by  a  plug  of  mucus  or  pus,  arrested  in 
the  catheter.  This  can  be  overcome  by  injecting  some  sterile  water 
into  the  catheter.  If  blood  appears  in  the  urine  which  is  being  collected, 
the  tip  of  the  catheter  should  be  pushed  a  little  higher  up,  so  that  it  is 
possible  to  exclude  an  injury  to  the  ureteral  mucous  membrane  through 
the  passage  of  the  catheter.  In  case  it  should  be  impossible  to  cathe- 
terize  one  ureter,  or  if  it  be  considered  undesirable  to  catheterize  the 
ureter  of  the  presumably  healthy  side,  the  so-called  balloon  catheter 
is  employed.  This  is  a  ureteral  catheter  whose  eye  is  covered  by  a  very 
thin  rubber  membrane.  After  this  catheter  is  inserted  into  one  ureter, 
the  rubber  is  inflated  by  means  of  a  syringe,  and  after  the  inflation  is 
finished  the  distal  end  of  the  catheter  is  tied.  In  this  way  the  catheterized 
ureter  is  plugged,  and  the  urine  coming  down  from  the  opposite  kidney 
is  collected  in  the  bladder  and  can  be  drained  out  by  an  ordinary  cath- 
eter. Previous  to  the  act  of  collecting  a  specimen,  the  bladder  must 
be  carefully  irrigated,  and  then  emptied. 

If  it  is  necessary  to  make  a  differentiation  between  a  complete 
severing  or  transverse  section  of  a  ureter  and  a  ureteral  fistula, 
which  involves  only  a  part  of  the  ureteral  wall,  ureteral  catheterization 
will  solve  this  problem  in  the  following  way:  In  case  of  a  complete 
lack  of  connection  between  the  distal  ureteral  stump  and  the  proximal 
end  of  the  ureter,  it  will  be  impossible  to  pass  the  catheter  beyond  the 
region  of  the  fistula,  and  at  the  same  time  the  distal  opening  of  the 
catheter  will  remain  dry.  If  only  a  parietal,  partial  lesion  of  the  ureter 
is  present,  quite  often  the  catheter  will  slip  over  this  place  beyond  the 
region  of  the  superficial  fistulous  opening,  and  urine  will  come  down 
through  the  catheter. 

The  emptying  of  a  fluctuating  tumor  occupying  the  renal  region, 
through  the  insertion  of  a  ureteral  catheter  inserted  high  up,  will  classify 
this  tumor  as  a  nephritic  one.  In  case  it  should  be  desirable  to  measure 
the  length  of  that  portion  of  the  catheter  which  is  inserted  into  the 
ureter  a  so-called  zebra  catheter  is  employed.  This  is  a  catheter  whose 
surface  is  marked  in  turn  by  yellow  and  black  spaces,  each  being  one 
centimeter  long.  By  counting  the  number  of  these  fields,  which  dis- 
appear into  the  ureteral  opening,  the  desired  measurement  is  secured. 
An  additional  aid  in  making  the  diagnosis  of  concretions  deposited  in 
the  renal  pelvis  may  be  had  by  the  use  of  the  ureteral  catheter. 

The  catheter  is  introduced  until  its  tip  rests  in  the  renal  ]:)elvis;  then 


734  METHODS    OF    EXAMINATION. 

sterile  water  is  injected  through  the  catheter  into  the  renal  pelvis.  If 
this  injection  is  followed  by  the  appearance  of  blood  in  the  urine,  which 
has  been  taken  from  this  kidney,  this  phenomenon  points  very  strongly 
to  the  presence  of  concretions,  whose  movement  as  the  result  of  the  in- 
jected stream  of  water  produced  hemorrhage.  If  a  wax-tipped  ureteral 
catheter,  after  being  withdrawn  from  the  renal  pelvis  and  ureter,  shows 
scratches  on  its  wax  coating,  absolute  evidence  is  furnished  of  the  exist- 
ence of  concretions. 

In  deciding  upon  the  patulency  of  a  ureter,  either  solid  sounds  or 
catheters,  strengthened  through  the  insertion  of  a  metalhc  mandrin, 
must  be  used.  All  these  instruments  should  be  well  lubricated  with 
glycerin  before  using.  It  must  be  remembered,  however,  that  the  mere 
fact  that  a  catheter  or  a  sound  meets  with  resistance  somewhere  in  the 
ureteral  canal,  does  not  prove  the  existence  of  some  permanent  obstruc- 
tion. Very  often  the  catheter  is  simply  caught  in  a  mucous  fold,  or  the 
mucosa  is,  by  virtue  of  some  inflammation,  swollen  to  such  an  extent  as 
to  impede  the  smooth  progress  of  the  catheter-tip.  This  is  especially 
true  for  the  vesical  part  of  the  ureters.  In  case  the  catheter  does  not 
progress  smoothly  and  warps,  several  methods  can  be  employed  in  order 
to  exclude  errors  in  the  above-mentioned  sense. 

Glycerin  of  vaselin  oil  is  injected  through  the  catheter  in  the  ureter, 
and  then  a  thicker  catheter  is  employed,  the  tip  is  repeatedly  twisted 
around,  so  as  to  extricate  it  out  of  an  interfering  fold  of  mucosa ;  in  case 
the  ureteral  opening  should  show  signs  of  inflammation,  a  few  drops 
of  adrenalin  solution  are  injected  into  the  vesical  end  of  the  ureter,  so 
as  to  cause  the  mucosa  to  contract  and  thus  reduce  the  swelling. 

The  diagnosis  of  a  stricture  of  the  ureter  can  only  be  made  if  a 
thinner  catheter  or  sound  passes  through  the  whole  length  of  the  ureter, 
after  a  previously  employed  larger  instrument  has  failed  to  do  so,  and 
if  the  sound,  after  having  passed  through  the  region  of  apparently 
reduced  lumen,  gives  the  examining  hand  the  distinct  impression  of 
being  "engaged." 

The  diagnostic  range  of  ureteral  catheterization  can  be  amplified 
by  its  combination  with  radiography  (Fig.  4,78).  If  a  metalhc  sound 
(lead  wire)  or  a  catheter  armed  with  a  metallic  stylet  is  introduced  into 
the  ureter  and  renal  pelvis,  and  an  :v-ray  picture  is  taken  while  the 
catheterizing  instrument  is  in  situ,  the  shadow  of  the  wire  will  appear 
in  the  x-ray  picture. 

The  following  information  can  thus  be  gleaned:  The  shadows  of 
the  wire  mark  the  course  of  the  ureter.  In  case  the  renal  pelvis  should 
be  enlarged  (dilated)  the  proximal  end  of  the  wire  adjusts  itself  to  the 


THE   NEWER   METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  735 

shape  of  the  pelvis,  outhning  its  extent  by  curhng  up  on  the  inner  surface 
of  the  pelvis.  In  case  one  or  more  concretions  are  present  in  the  kidney, 
their  topographic  position  can  be  determined;  if  the  shadow  of  the 
wire-tip  is  in  direct  connection  with  the  shadow  of  the  concretion,  the 
diagnosis  of  a  pelvic  stone  is  made;  if  the  shadow  of  the  concretion 
appears  inside  the  shadow  of  the  kidney  at  a  distance  from  the  wire-tip, 
the  diagnosis  of  a  concretion  inside  of  the  renal  parenchyma  is  made; 
its  exact  location  can  be  determined  by  judging  the  distance  of  its  shadow 
from  the  shadow  of  the  wire-tip. 


Fig.  478. — liADiOGRAPH  OF  Suspected  Renal  Calculus  with  Sound  in  Ureter  (E.  Hurry  Fenwick). 

The  arrow  points  to  a  shadow  which  was  shown  to  lie  outside  of  the  ureter,  the  latter  being  filled  with  a 

shadowgraph  bougie.     The  shadow  proved  to  be  a  patch  in  an  atheromatous  artery. 

If  small  round  shadows  appear  in  the  picture  somewhere  alongside 
the  course  of  the  ureter,  it  can  be  determined  whether  these  shadows 
are  produced  by  ureteral  concretions  or  not. 

Ureteral  concretions  will  necessarily  produce  shadows  that  are  in 
intimate  relation  to  the  shadow  produced  by  the  wire  lying  in  the  ureter. 
Other  conditions  which  produce  shadows,  not  in  close  relation  to  the 
sound,  are  calcified  mesenteric  lymph-nodes,  phleboliths  in  the  veins  of 
the  pelvis,  areas  of  ossification  in  the  ligaments  of  the  pelvis. 


/o 


6  ilETHODS    OF   EXAillXATIOX. 


If  the  shadow  of  the  wire  leads  directly  into  the  shado^^w  outHne 
of  a  tumor,  the  connection  of  tliis  tumor  with  the  kidney  is  estabhshed. 

The  collection  of  urine  separately  from  each  kidney  renders  it 
possible  to  determine  Avhich  kidney  or  whether  both  are  diseased,  (a) 
by  the  microscopic  and  chemical  analysis  of  the  collected  specimens; 
and  (b)  it  furthermore  enables  the  examiner  to  investigate  the  func- 
tional capacity  of  either  kidney. 

Cystoscopy. 

Cystoscopy  is  the  ocular  inspection  of  the  inner  surface  of  the  urinary 
bladder,  accomplished  by  means  of  appropriately  constructed  instru- 
ments. 

Under  special  conditions  the  vesical  end  of  the  posterior  urethra 
also  becomes  accessible  to  inspection.  ISIodern  cystoscopy  rests  upon 
the  follo"UTtig  principles: 

(a)  The  discus  is  dilated  by  means  of  the  inflation  of  air,  or  through 
a  transparent  watery  fluid  which  has  been  injected  into  the  bladder. 

(b)  Through  the  insertion  of  an  incandescent  electric  light  into  the 
bladder,  and  the  enlarging  of  the  virtual  picture,  either  by  a  lens  inserted 
in  the  instrument  used  or  through  the  combination  of  a  prism  and  lens 
by  means  of  a  telescope-Kke  arrangement  (Figs.  479  and  480). 

The  cystoscopes  most  often  used  belong  either  to  the  group  which 
furnish  inverted  pictures  or  they  belong  to  a  second  group  wliich  furn- 
ish a  direct  view,  that  is,  an  upright  picture.  To  the  iirst-mentioned 
class  of  instruments  belongs  the  so-called  retrospective  cystoscope,  wliich 
by  a  pecuhar  optic  arrangement  permits  the  inspection  of  the  internal 
orifice  of  the  urethra  and  of  the  extreme  inner  part  of  the  posterior 
urethra.  The  addition  of  conducting  canals  converts  the  cystoscopes 
into  instruments  which  can  be  used  for  ureteral  catheterization  and  for 
operative  procedures. 

The  second  group  of  cystoscopic  instruments  includes  those  wliich 
furnish  a  direct  view,  that  is,  upright  pictures.  The  addition  of  con- 
ducting canals  transforms  these  instruments  also  into  cystoscopes  which 
can  be  employed  for  ureteral  catheterization  and  for  endovesical  opera- 
tion. 

In  order  to  determine  the  topographic  location  of  various  lesions 
we  resort  to  conclusions  drawn  from  (a)  the  position  of  the  ocular  end 
of  the  instrument,  and  (b)  from  the  relation  of  the  lesion  under  question 
to  certain  landmarks  on  the  inner  surface  of  the  bladder. 

A  Httle  knob  soldered  to  the  circumference  of  the  ocular  part,  in 
the  same  sagittal  plane   as  the   convexity  of  the  beak,  indicates  the 


THE   NEWER  METHODS   OF   DIAGNOSIS,  OF   RENAL   LESIONS.  737 

position  of  the  cystoscopic  window,  and  thus  the  location  of  the  object 
in  view. 

A  further  more  precise  determination  is  furnished  by  the  following 
intravesical  landmarks : 

1.  The  internal  orifice  of  the  urethra.  It  appears  under  normal 
conditions  as  a  crescent-shaped  fold  of  dark  red  color,  only  shghtly 
glossy,  and  of  velvety  surface. 

2.  The  intraureteric  hgament.     It  presents  itself  as  a  small  band, 


Fig.  479. — Brenner's  Ureter-cystoscope. 


Fig.  480. — Nitze's  Cystoscopes. 


more  or  less  prominent,  running  in  a  transverse  direction  through  the 
field  of  view  covering  the  trigonum. 

3.  The  ureteral  openings,  appearing  at  either  end  of  the  above- 
described  band. 

4.  The  air-bubble,  naturally  always  floating  on  top  of  the  tilhng 
fluid,  thus  indicating  the  vertex  of  the  bladder.  This  bubble  shows 
silvery  reflexes,  is  translucent,  and  in  its  center  the  reflex  of  the  incan- 
descent hght  is  to  be  seen;  it  oscillates  according  to  the  respiratory 
movements. 

The  normal  color  of  the  mucosa  of  the  bladder  is  a  light  yellow 
47 


738  METHODS    OF   EXAMINATION. 

with  a  pinkish  or  grayish  tinge,  and  the  ramifications  of  tlie  blood-vessels 
are  distinctly  to  be  seen;  the  surface  of  the  vesical  mucosa  is  smooth 
and  glossy,  and  any  deviation  from  one  or  from  several  of  these  conditions 
points  to  pathology. 

The  ureteral  openings  appear  normally  as  fine  slits  of  a  somewhat 
darker  color  than  the  surrounding  mucosa,  only  during  the  ejaculations 
of  urine  are  these  slits  transformed  temporarily  into  holes;  a  ureteral 
opening  of  a  dark  red  color  or  a  permanent  gaping  of  the  ureteral  mouth 
is  pathologic. 

Cystitis. — Acute  inflammation  of  the  mucosa  characterizes  itself 
by  the  change  of  the  normal  color  to  a  red  of  dift'erent  shades,  and  by 
the  disappearance  of  the  blood-vessels  in  the  affected  areas;  in  the 
adjacent  parts,  the  blood-vessels  appear  to  be  injected  and  dilated. 
The  intensity  of  the  coloring  is  in  proportion  to  the  intensity  of  the  in- 
flammatory process. 

In  cystitis  that  occurs  in  circumscribed  patches,  areas  of  mucosa  of 
normal  appearance  separate  the  dark  spots;  if  the  cystitis  is  of  a  general 
character,  large  areas  appear  dark  red,  without  showing  any  blood- 
vessels, or  the  whole  surface  of  the  mucosa  is  dark  red,  and  of  velvety 
appearance. 

In  case  of  intense  inflammation  shreds  of  epithelium  are  attached 
by  one  end  to  the  inflamed  areas,  and  submucous  hemorrhages  are  to  be 
seen  in  the  immediately  adjacent  parts. 

Acute  gonorrheal  cystitis  is  characterized  by  the  confinement  of  the 
process  to  the  trigonum,  that  appears  to  be  studded  with  red  spots  of 
various  sizes;  the  greatest  intensity  of  coloring  is  found  in  the  centers 
of  these  blotches,  the  coloring  tapering  to  pink  in  the  periphery  of  these 
foci. 

Chronic  cystitis  is  characterized  by  the  changing  of  the  red  color 
into  a  more  brownish  shade,  the  surface  of  the  affected  parts  is  without 
any  gloss  whatever,  and  the  hemorrhagic  spots  appear  to  be  black. 

The  mucosa  is  quite  often  swollen  and  raised  into  thick  clumsy 
folds,  impressing  the  inexperienced  eye  at  first  glance  as  neoplastic 
formations.  They  can  be  differentiated  from  polypi  in  the  following 
ways:  Polypi  have  not  such  a  broad  insertion;  polypi  are,  at  least  at 
their  ends,  translucent;  and  if  transillumined  show  very  distinctly  their 
blood-vessels,  while  folds  of  the  swollen  mucosa  are  absolutely  opaque. 

The  products  of  cystitis  in  chronic  cases  appear  either  as  lumps  of 
a  whitish  appearance  and  of  a  frowsy  surface,  attached  to  discolored 
parts  of  the  mucosa,  or  they  cover,  formed  into  membranes,  the  depen- 
dent parts  of  the  bladder. 


THE   NEWER  METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  739 

In  some  cases  of  long  standing  the  chronic  inflammation  leads  to 
the  formation  of  villous  excrescences  around  the  internal  urethral 
orifice  and  on  the  adjacent  parts  of  the  bladder  entrance. 

These  formations  remind  one  of  a  glove  in  miniature.  They  are  not 
transparent,  and  give  distinctly  the  impression  of  jelly-like  infiltration. 

Cystitic  Ulcers. — They  appear  in  the  cystoscopic  view  as  fossettae 
sunken  down  into  round  elevations;  their  bottom  is  covered  with  a 
grayish  coat;  the  elevations  are  located  in  cystic  brownish-colored 
areas;  their  favorite  location  is  in  the  trigonum. 

Tuberculosis  of  the  Bladder. — A.  Tuberculous  Catarrh  or  Tuber- 
culous Parenchymatous  Cystitis. — K  large  area  of  the  mucosa  appears 
to  be  reddened.  The  blood-vessels  in  the  involved  area  are  not  to  be 
seen,  the  whole  surface  being  smooth  and  giving  the  impression  of  a 
gelatinous  swelling.  Numerous  ecchymoses  are  also  to  be  seen.  The 
inflamed  area  is  extremely  sensitive  to  the  touch  and  the  capacity  of 
the  bladder  is  always  markedly  reduced.  This  picture,  of  course,  in- 
dicates only  a  suspicion  of  tuberculosis.  The  final  diagnosis  can  only 
be  made  by  finding  tubercle  bacilli  in  the  urine. 

B.  Nodular  and  Ulcerative  Tuberculous  Cystitis. — In  the  trigone 
one  most  frec^uently  sees  nodules  of  different  sizes,  varying  from  the 
size  of  a  hempseed  to  that  of  a  lentil.  These  nodules  are  of  a  grayish  or 
yellowish  color,  surrounded  by  a  dark  red  margin. 

Some  of  these  nodules  are  broken  down  in  the  center,  so  that  small 
ulcers  result.  Their  edges  are  undermined,  raised,  and  ragged.  In 
more  advanced  cases,  two  or  three  of  these  ulcers  may  become  confluent, 
thus  forming  a  larger  ulcer  of  irregular  outline.  The  floor  of  these 
ulcerations  is  covered  by  pale,  irregular  granulations,  which  bleed  very 
easily. 

If  these  nodules  or  ulcers  are  grouped  around  a  ureteral  opening, 
■or  if  the  ureteral  mouth  shows  signs  of  inflammation,  if  it  is  gaping, 
red,  and  its  lips  swollen,  or,  if  the  ureteral  opening  forms  the  central 
part  of  such  an  ulcer,  the  diagnosis  of  descending  tuberculosis,  origina- 
ting in  the  kidney,  is  almost  certain.  Here  again  the  final  diagnosis 
rests  upon  finding  tubercle  bacilli. 

C.  Tuberous  Form  of  Tuberculosis. — We  see  one  or  two  solitary 
tumor-like  excrescences  of  various  thickness  and  height  protrude  from 
a  red,  darkened  area  of  the  mucosa:  The  top  of  such  a  prominence 
always  carries  an  ulcer,  with  ])uffy,  ragged  edges;  its  bottom  is  covered 
by  easily  bleeding  granulations.  This  form  of  tuberculosis  preferably 
appears  near  the  internal  orifice  or  in  the  vertex  of  the  bladder. 

Solitary  Ulcers. — These  ulcers  may  appear  anywhere  in  the  bladder. 


740  METHODS    OF    EXAMIXATIOX. 

Thev  are  surrounded  by  apparendy  healthy  mucosa  of  normal  color, 
gloss,  and  vascular  ramification.  Their  contour  is  quite  round,  the 
edges  are  sharp,  and  the  floor  is  covered  with  sohd  red  granulations. 
The  ulcer  is  below  the  level  into  the  mucosa,  and  it  appears  as  though 
stamped  out  of  the  lining  with  a  sharp  die.  These  ulcers  are  rare,  and 
appear  almost  exclusively  in  young  individuals. 

Edema  of  the  Bladder. — In  general  edema  of  the  bladder,  the  mucosa 
appears  to  be  thrown  up  into  thick  clumsy  folds.  The  color,  if  no 
acute  inflammator}'  conditions  of  the  Hning  are  coexistent,  is  whitish. 
I'he  blood-vessels  are  not  to  be  seen.  The  surface,  especially  the  crest 
of  the  folds,  appears  as  if  covered  with  glistening  white  scum. 

Circumscribed  edema  shows  limited  areas  of  the  mucosa  teased 
apart  at  the  surface,  so  that  the  affected  part  of  the  mucosa  appears  hke 
a  flake  of  wet,  white  absorbent  cotton  (retrostrictural  edema). 

Inflammatory  tumors,  in  becoming  attached  to  the  bladder  waU, 
produce  a  certain  kind  of  circumscribed  edema,  which  is  pecuhar  to 
the  bladder  mucosa.  On  account  of  the  characteristic  appearance 
and  the  patholog}-,  it  is  called  bullous  edema. 

The  aft'ected  area  of  the  mucosa  appears  to  be  covered  Avith  any 
number  of  translucent  globuli,  whose  sizes  vary  from  that  of  a  lentil 
to  that  of  a  large  pea.  In  difl'erent  places  white  flakes,  attached  by  one 
end  to  the  mucosa,  float  in  the  fluid,  which  has  been  injected  into  the 
bladder.  . 

If  these  globuli  are  closely  crowded  together,  the  whole  affected 
parts  offer  the  appearance  of  a  cluster  of  small  grapes.  The  base  and 
the  adjacent  mucosa  appear  reddened,  quite  often  wrinkled. 

If  the  inflammatorv  tumor  Avhich  has  produced  the  condition  pushes 
the  bladder  waU  into  the  lumen  of  the  discus,  and  if  a  great  many  of 
these  globuH  have  burst  on  account  of  the  tension,  the  whole  afl'ection 
may  be  mistaken  for  a  neoplasm. 

Prostatic  Hypertrophy. — Changes  in  the  size  and  formation  of 
the  prostate  gland  become  visible  inside  of  the  viscus,  and  can  be  diag- 
nosed through  the  cystoscope,  if  the  vesical  surface  of  the  gland  is  the 
main  seat  of  the  afl'ection. 

Any  change  in  the  normally  crescent-shaped,  sharp  outhne  of  the 
internal  orifice,  as  it  appears  in  the  cystoscopic  view,  points  to  abnor- 
malities in  the  prostate. 

It  is,  however,  important  to  miake  allowance  for  an  indentation  of 
the  urethral  canal,  if  the  ocular  end  of  the  cystoscope  is  markedly 
elevated. 


THE   NEWER   METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  74I 

If  one  lateral  lobe  is  enlarged,  one  side  of  the  circumference  appears 
to  be  elevated  and  protruding  into  the  field  of  view. 

If  such  a  lateral  lobe  is  considerably  enlarged,  and  grows  into  the 
bladder,  a  hilly  prominence  in  the  so-called  vesical  neck  is  to  be  seen. 
If  prostatitis  is  present  the  mucosa  covering  this  prominence  appears 
edematous.  If  both  lateral  lobes  are  enlarged,  the  aspect  of  the  internal 
orifice  is  changed  into  a  V-shape.  If  both  lateral  lobes  grow  into  the 
viscus,  several  prominences  elevating  the  mucous  membrane  of  the 
trigonum  are  to  be  seen.  If  the  median  lobe  is  moderately  and  uniformly 
enlarged  the  crescent-shaped  outhne  of  the  internal  orifice  of  the  urethra 
appears  to  be  fiat. 

If  this  uniform  enlargement  reaches  a  higher  degree,  the  concave 
outline  of  the  internal  orifice  is  changed  into  a  convex  one. 

If  the  median  lobe  becomes  pedunculated,  and  if  the  upper  part  of 
it  keeps  on  growing,  the  cystoscope  reveals  a  pedunculated  valve  hanging 
across  the  internal  orifice. 

A  uniform  enlargement  of  the  prostate  not  only  changes  the  outline 
of  the  internal  orifice  into  a  straight  or  even  into  a  convex  line,  but  it 
also  shows  the  resulting  base  of  the  bladder  as  a  deep  valley,  whose 
bottom  appears  dark  on  account  of  the  shadow.  All  these  findings 
are  more  distinctly  and  markedly  seen  through  the  employment  of  the 
retrospective  cystoscope. 

In  case  arteriosclerosis  is  the  cause  of  the  prostatic  trouble,  thick, 
rigid-appearing  blood-vessels  are  to  be  seen  meandering  through  the 
mucosa  covering  the  prostate;  these  blood-vessels  spring  into  promi- 
nence like  strands  buried  in  the  mucosa. 

As  a  rule,  we  see  tiny  blood-streams  trickhng  down  from  these 
places,  which  were  touched  in  introducing  and  manipulating  the  cysto- 
scope. 

Vesical  Calculi. — Bladder  stones  present  themselves  in  the  cvsto- 
scopic  view  as  well-defined  foreign  bodies,  that  distinguish  themselves 
sharply  from  the  bladder  wall. 

As  to  any  conclusions  regarding  their  size,  it  must  be  remembered 
that  only  at  a  certain  distance  (var3-ing  according  to  the  lens  S3^stem 
employed)  from  the  window,  objects  will  appear  in  their  natural  size, 
otherwise  they  become  magnified  in  the  cystoscopic  observations. 
Furthermore,  if  a  concretion  is  so  large  that  it  extends  beyond  the 
cystoscopic  field  of  view,  we  only  get  a  constructive  picture  of  the  whole 
stone;  but  we  can  always  arrive  at  a  pretty  accurate  conclusion  as  to  the 
size  of  the  stone  if  we  observe  its  distance  from,  or  its  extension  over, 
the  aforementioned  landmarks  inside  of  the  bladder. 


742  METHODS    OF   EXAMINATION. 

Further  information  as  to  whether  a  stone  is  freely  movable  or 
partially  embedded  between  folds  of  mucous  membrane,  or  whether 
it  is  encysted  to  any  extent  in  a  diverticulum,  can  be  gained  by  using  a 
ureteral  or  operative  cystoscope  through  whose  conducting  canal  we 
introduce  a  sound  or  a  forceps. 

By  trying  to  move  the  stone  or  by  dislodging  it,  all  points  may  be 
cleared  up,  upon  which  we  desire  information.  With  the  aid  of  the 
cystoscope,  we  observe  the  color  of  the  concretion,  the  quality  of  its 
surface,  and  its  general  formation.  Phosphates  and  lime-stones  appear 
as  white  foreign  bodies,  which,  as  a  rule,  are  egg-shaped. 

Urates  show  a  yellowish  color  and  a  round  form.  Oxalates  are 
either  brown,  or  of  a  blackish-brown;  occasionally  they  show  a  black- 
greenish  tinge.  Their  general  formation,  as  a  rule,  is  rather  irregular, 
their  surface  is  granular,  and  in  marked  forms  they  appear  like  mulberries. 

The  cystoscope  decides  very  readily  whether  only  one  or  many  stones 
are  present.  If  we  discover  facets  on  the  surface  of  one,  this  is  a  strong 
indication  to  look  for  other  calculi.  If  cystitis  or  traumatic  ulcerations 
are  present,  we  discover  these  readily  by  ocular  inspection.  In  a  differ- 
ential diagnostic  way,  large  blood  coagula  or  pus  coagula  deserve  to  be 
mentioned.  Blood  coagula  have  quite  a  characteristic  yellow,  leathery 
appearance;  their  surface  is  absolutely  smooth,  much  more  so  than  that 
of  any  stone.  Large  masses  of  pus  appear  to  be  strongly  light- reflecting, 
almost  white,  like  small  snowballs,  and  their  surface  shows  a  very 
loose  structure. 

Tumors  of  the  Bladder  Wall. — Neoplasms  of  the  bladder  appear 
in  the  cystoscopic  field  as  protrusions  that  are  attached  to  the  bladder 
wall  at  one  end,  and  extend  into  the  lumen  of  the  viscus  at  the  other. 
This  standing  out  in  relief  is  characteristic  of  neoplasms.  It  is  very 
pronounced,  if  the  tumors  are  pedunculated.  If  the  tumors  are  attached 
to  the  bladder  wall  by  a  broad  basis  it  is  less  pronounced.  If  a  neo- 
plasm infiltrates  the  bladder  wall,  this  standing  out  in  relief  is  least 
pronounced.  In  the  latter  case,  a  preliminary  symptom  is  quite  char- 
acteristic, viz.,  when  we  try  to  dilate  the  bladder  by  injecting  water 
by  means  of  a  hand-syringe,  we  experience  an  exquisite  sensation  of 
rigid  resistance.  The  cystoscopic  pictures  are  very  clear  and  easily 
recognized  and  classified  if  no  cystitis  is  coexistent.  The  tumor-mass, 
not  showing  any  blood-vessels,  and  being  of  a  different  color,  can  be 
differentiated  very  readily  from  the  normal  mucosa.  The  impression 
of  something  solid  is  strengthened  by  the  appearance  of  the  shadows 
that  are  cast  by  the  tumor  over  the  mucosa. 

These  shadows  change  their  position  according  to  variations  in  the 


THE   NEWER  METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  743 

position  of  the  cystoscopic  beak.  Swollen,  thick  mucosa  folds  may 
occasionally  simulate  neoplasms.  The  following  points  will  aid  in 
distinguishing  these  swollen  folds  of  mucous  membrane  from  tumors. 
The  folds  when  swollen  are  always  multiple,  which  is  rather  rare  in 
tumors.  The  folds  appear  as  diffuse  swellings,  while  neoplasms  appear 
to  be  more  sharply  defined.  Swollen  mucosa  folds  show  over  their 
entire  surface  a  whitish,  glistening  scum. 

Malignant  tumors,  as  a  rule,  ulcerate  on  their  surface,  and  then 
present  on  their  summit  an  irregularly  shaped  ulceration,  which  almost 
uniformly  bears  incrustations.  If  a  neoplasm  occurs  in  a  cystitic 
bladder,  or  if  a  neoplasm  is  ulcerated,  a  certain  method  must  be  employed 
in  order  to  obtain  good  views.  After  the  instrument  is  introduced,  it 
must  be  kept  quiet  for  a  while,  so  as  to  give  the  particles  of  debris  and 
pus  iioating  in  the  fluid  a  chance  to  settle  down  to  the  most  dependent 
parts  of  the  bladder.  The  so-called  villous  polypi  or  papillomata  of 
the  bladder  give  very  beautiful  and  characteristic  views.  As  a  rule, 
they  grow  from  a  common  pedicle,  which  divides  into  several  branches. 
These  show  a  leaf-like  appearance,  and  float  around  like  water-plants 
in  the  fluid  which  has  been  employed  to  fill  the  bladder. 

If  the  light  is  allowed  to  pass  through  these  leaves  they  show  quite 
distinctly  long  loops  of  blood-vessels.  Some  of  these  tumors  show  at 
their  edges  a  fimbriated  condition. 

iVll  these  tumors  are  of  a  benign  nature,  and  contact  may  produce 
free  hemorrhage.     Other  tumors  imitate  the  shape  of  a  mushroom. 

Malignant  tumors  show,  besides  the  ulceration  already  referred  to, 
an  irregular  surface,  there  being  recesses  or  excavations  and  hemorrhages 
in  the  adjacent  mucosa.  An  extensive  phlegmon  of  the  mucosa  in  its 
initial  stages  can  hardly  be  differentiated  from  an  infiltrating  cancer 
in  the  cystoscopic  view.  The  diagnosis  can,  however,  be  made  from 
the  accompanying  symptoms  of  each  condition. 

Encrusted  tumors  may  occasionally  be  mistaken  for  calculi  and 
vice  versa.  The  employment  of  an  operative  cystoscope  and  the  ma- 
nipulation of  the  questionable  object  by  a  forceps  introduced  through 
it  will  assist  in  making  a  differential  diagnosis. 

In  rare  cases  a  blood  coagulum  attached  with  one  end  to  the  bladder 
wall  and  floating  around  with  its  free  end  may  be  taken  for  a  polypus. 
Close  observation  of  its  surface,  and  the  lack  of  any  translucency,  even 
at  the  edges,  will  iinally  settle  the  diagnosis. 

Parasites  of  the  Bladder. — Parasites  on  and  in  the  bladder  wall 
produce  a  cystitis  of  the  following  character.  The  cystoscope  shows 
reddish  patches  disseminated  all  over  the  inner  surface.     Adherent  to 


744  METHODS    OF   EXAMINATION. 

the  centers  of  these  foci  of  inflammation  are  whitish  or  yehowish  gran- 
ular areas.  These  granules  are  not  as  flat  as  the  covering  of  ordinary 
ulcers,  but  protrude  into  the  viscus,  and  show  strong  reflecting  power. 
These  granules  are  formed  by  the  mycelia  of  the  parasite,  whose  char- 
acter must  be  determined  by  microscopic  examination. 

Syphilis  of  the  Bladder  Wall. — Syphihs  of  the  bladder  produces 
various  cystoscopic  pictures,  according  to  the  luetic  lesions  present. 
Condylomata  lata  (mucous  patches)  appear  as  yellowish  prominences 
of  the  well-kno^^Tl  form.  Syphihtic  ulcers  do  not  differ  from  those  of 
other  infections  in  appearance.  Gummata  elevate  the  mucosa,  and 
after  breaking  do^Mi  show  central  ulcerations.  The  diagnosis  can  only 
be  made  positive  through  antisyphilitic  medication. 

Leukoplakia  of  the  Bladder. — This  condition  manifests  itself  in  the 
cystoscopic  view  by  the  appearance  of  white  patches,  located  in  the 
trigonum  or  at  the  junction  of  the  base  of  the  bladder  to  the  fundus. 
These  patches  are  somewhat  prominent  above  the  surface  of  the  mucosa, 
are  of  oval  or  circular  shape,  and  vary  in  size  from  a  diameter  of  3  to  6 
mm.  The  surface  of  these  patches  appears  to  be  of  sohd,  dense  struc- 
ture. If  these  patches  are  in  a  condition  of  reaction,  showing  a  lighting 
up  of  a  cystitis,  they  have  a  scarlet-red  small  periphery,  and  the  blood- 
vessels in  the  adjacent  mucosa  appear  to  be  injected. 

Patent  Urachus. — In  this  condition  we  see  at  the  top  of  the  bladder 
a  round  hole,  surrounded  by  a  rim  of  protruding,  highly  vascularized, 
smooth,  shiny  mucosa.  The  center  of  this  opening  is  dark.  A  ureteral 
catheter  introduced  into  this  shadowy  center  proceeds  without  any 
obstruction  for  several  inches  in  an  upward  direction. 

In  case  inflammation  has  occurred  around  tlie  opening  of  the  urachus 
into  the  bladder,  the  ring  of  mucous  membrane  encirchng  the  opening 
appears  to  be  swollen;  ribbons  of  detached  epithelial  covering  project 
into  the  lumen  of  the  bladder,  and  pus  flakes  are  seen  to  drop  from  the 
opening  of  the  urachus  into  the  bladder.  In  the  mucosa  adjoining  the 
opening  numerous  submucous  hemorrhagic  patches  are  to  be  seen. 

Abnormal  Communication  of  the  Bladder  with  Some  Preformed 
Cavity  or  Some  Perivesical  Area  of  Infection,  etc. — The  perforation  of 
a  pelvic  abscess  into  the  bladder  is  marked  in  the  cystoscopic  picture 
by  a  bulging  of  the  aft'ected  bladder  area  into  the  lumen.  If  the  exu- 
date is  still  under  high  tension,  this  part  of  the  mucosa  is  covered  with 
edema  bullosum.  If  the  tension  has  considerably  relaxed,  the  mucosa 
appears  to  be  generally  swollen,  but,  as  a  rule,  a  few  pearls  of  circum- 
scribed edema  are  to  be  noticed  in  the  otherwise  generally  edematous 
mucosa. 


THE   NEWER   METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  745 

The  perforation  appears  as  a  ragged  hole,  whose  edges  are  everted. 
The  border  is  covered  with  pus  flakes  and  with  ribbons  of  the  detached 
epithehal  layer.  The  adjacent  mucosa  is  dark  red,  the  vascularization 
is  no  longer  visible.  Ecchymoses  are  numerous,  and  quite  often  we  see 
a  thin  stream  of  pus  running  down  into  the  bladder.  Pressure  on  the 
inflammatory  tumor  increases  the  flow  of  pus  into  the  bladder.  The 
pus  accumulates  in  the  trigonum  and  fundus,  and  appears  there  as  a 
white,  strongly  reflecting  mass. 

The  perforation  of  a  pyosalpinx  shows  a  similar  picture,  but  the 
bladder  wall,  as  a  rule,  is  involved  in  the  inflammatory  changes  only  to 
a  very  limited  extent.  As  a  rule,  no  flow  of  pus  into  the  bladder  is  to 
be  noticed.  Pressure  on  the  pyosalpinx  makes  corrugated,  sausage- 
shaped  strands  of  pus  appear  in  the  perforation.  If  the  pressure  is 
kept  up,  these  strands  accumulate  and  are  arranged  in  loops  at  the  fun- 
dus, thus  giving  the  appearance  of  a  network  of  white,  strongly  reflect- 
ing strands. 

The  perforation  of  a  dermoid  cyst  shows  similarly  an  opening  sur- 
rounded by  the  signs  of  contiguous  inflammation.  Either  bunches  of 
hair,  covered  with  caseous  masses,  or  parts  of  the  bony  skeleton  can  be 
seen  protruding  into  the  bladder. 

Vesicorectal  fistulas  may  become  the  object  of  cystoscopic  examina- 
tion if  the  fistula  is  a  tortuous  one,  or  if  the  rectal  fistulous  opening  is 
so  small  that  it  can  easily  be  closed  temporarily  by  packing.  In  either 
case  it  becomes  possible  to  dilate  the  bladder  for  a  sufficient  length  of 
time  to  permit  a  cystoscopic  examination  to  be  made. 

The  vesical  opening  of  such  a  fistula  always  appears  hke  a  crater, 
drawn  in  toward  the  bowel,  so  that  concentric  longitudinal  folds  of 
mucous  membrane  appear.  The  border  of  the  fistula  appears  to  be 
smooth  and  the  mucosa  tense  over  it.  The  signs  of  inflammatory 
reaction  around  the  fistulous  opening  are  very  slight.  Once  in  a  while 
fragments  of  feces  may  be  seen  adherent  to  the  edges. 

Vesicovaginal  fistulas  can  be  rendered  accessible  for  cystoscopic 
examination  either  by  clamping  together  the  edges  of  the  communication 
or  by  tightly  packing  the  vagina  with  wet  cotton. 

The  vesical  opening  of  the  fistula  is  always  surrounded  by  an  in- 
flamed area  of  mucosa;  the  most  important  feature  of  this  examination 
is  to  determine  what  relation  the  ureteral  openings  bear  to  the  fistula. 

The  communication  of  the  bladder  with  a  loop  of  intestine,  as  a 
result  of  the  perforation  of  an  intestinal  carcinoma  into  the  bladder, 
gives  quite  a  striking  picture. 

In  the  fundus,  or  in  tlic  vertex  of  the  bladder  anywhere,  we  see  a 


746  METHODS    OF    EXAMINATION. 

dark  excavation  of  varying  size.  This  recess  sliows  a  double  border. 
In  the  inner  part  the  smooth  mucosa  of  the  intestine,  sliiny  and  pinkish, 
protrudes  into  the  viscus.  In  some  places  we  see  ulcerated  portions 
of  the  neoplasm.  Irregular  craters  with  a  discolored  base,  their  edges 
ragged,  and  ribbons  of  necrosing  tissue  floating  from  their  periphery, 
are  seen.  The  outer  ring  of  the  edge  is  formed  by  the  vesical  mucosa. 
It  appears  to  be  dark,  velvety  red,  and  submucous  hemorrhagic  patches 
are  to  be  seen.  The  adjacent  mucosa  is  characterized  by  a  very  dense 
network  of  the  finest  blood-vessels. 

Hemorrhoids  of  the  Bladder. — Simple  dilated  large  veins  appear 
in  the  cystoscopic  picture  as  meandering  blue  strands  of  various  caliber; 
they  quite  often  protrude  above  the  level  of  the  mucosa.  True  "hem- 
orrhoids," that  is,  well-developed  phlebectasias,  parietal  dilatations, 
or  pockets  in  the  veins,  give  different  cystoscopic  pictures,  according 
to  their  relation  to  the  cystoscopic  beak. 

If  the  light  strikes  them  from  the  front  or  diffusely,  they  appear  as 
well-defined  blue  globules  with  a  smooth  surface.  If  they  are  transil- 
lumined  from  behind,  they  appear  as  reddish,  somewhat  transparent 
globules,  that  frequently  carry  a  dark  center  ("phlebohths").  Once 
in  a  while  a  floating-blood  coagulum  is  seen  to  be  attached  to  the  periph- 
ery of  such  a  nodule.  In  order  to  test  the  functional  capacity  of  the 
two  kidneys,  several  methods  are  in  use: 

Chromocystoscopy. 

Drugs  which  stain  the  urine  are  brought  into  the  circulation  after 
being  swallowed  or  by  intramuscular  injections.  These  drugs  after  a 
certain  length  of  time  (thirty  minutes)  color  the  urine.  If  this  coloring 
is  delayed  in  its  appearance,  or  if  the  intensity  of  the  coloring  is  lessened, 
the  kidney  is  considered  to  be  below  par.  Methylene-blue  can  be  given 
by  mouth,  and  for  intramuscular  injections  a  4  per  cent,  indigo-carmin 
solution  is  used.  The  limitations  of  this  method  of  chromocystoscopy 
are  obvious.  In  the  first  place,  we  have  no  sliding  scale  that  would 
enable  us  to  draw  reliable  conclusions  as  to  the  time  the  stain  appears 
in  the  urine  or  from  the  intensity  of  the  coloring. 

It  is  a  matter  of  experience  that  normal  kidneys  show  great  varia- 
tions as  to  both  of  these  points,  and  that  not  infrequently  diseased 
kidneys  act  very  promptly  as  to  these  signs.  The  only  diagnostic  point 
that  can  be  gained  by  this  method  is,  if  a  stained  urine  is  ejaculated 
from  both  ureteral  openings,  then  we  are  dealing  with  two  functionating 
kidneys  and,  considering  the  rarity  of  a  horseshoe  kidney,  we  can  say 
with  strong  probability  that  two  functionating  kidneys  are  present. 


THE   NEWER   METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  747 


Cryoscopy. 

Crvoscopy  is  the  determination  of  tlie  molecular  concentration  of 
the  urine  and  blood  by  deter- 
mining their  respective  freez- 
ing-point. The  principle  of 
this  method  is  this :  The  richer 
a  given  substance  is  in  regard 
to  molecules,  the  lower  will  its 
freezing-point  be  below  that 
of  distilled  water.  The  best 
apparatus  to  use  is  that  of 
Boeckmann  (Fig.  481). 

Under  normal  conditions 
the  urine  is  more  concentrated 
as  to  molecules  than  the  blood. 
If  comparison  between  the 
freezing-point  of  the  blood  and 
of  water  show  that  this  normal 
difference  is  diminished,  then 
the  functional  capacity  of  the 
kidney,  i.  e.,  its  eliminative 
power,  is  diminished. 

In  other  words,  the  ques- 
tion to  be  answered  is  whether 
one  kidney  will  be  sufficient  to 
attend  to  the  necessary  elimina- 
tion after  the  other  has  been 
removed. 

Normally  the  human  blood 
has  a  freezing-point  of  0.56°  C. 
lower  than  the  freezing-point 
of  distilled  water.  If  this  freez- 
ing-point of  the  blood  sinks 
lower  than  the  above-men'- 
tioned  figure,  then,  according 
to  those  who  recommend  this 
method,  we  must  conclude  that 
there  is  retention,  consequently  pic.  481. -apparatus  for  ;cRvoscopY:(Fowier). 

an  increase  of  the  molecules  in 
the  blood,  caused  by  an  insufficient  kidney  action.     A  normal  freezing- 


748  METHODS    OF   EXAMIXATION. 

point  does  not  always  indicate  renal  sufficiency.     A  high  freezing-point 
may  be  jound  when  the  kidneys  have  a  perfect  junctional  capacity. 

If  the  deviation  is  more  than  0.59°  C.  it  is  not  advisable,  as  a  rule, 
to  extirpate  a  kidney.  The  freezing-point  of  the  urine  normally  is 
from — 1.3°  to  2.0°  below  the  freezing-point  of  water;  a  deviation  beyond 
tliis  limit  proves  the  kidney  to  be  unreliable,  showing  that  the  molecular 
concentration  of  the  urine  is  unusually  low.  We  must  be  sure  that  no 
polyuria  exists  in  order  that  it  may  be  of  value.  Extensive  investiga- 
tions have  proved  that  this  method  is  only  rehable  if  the  results  are 
positive. 

Phloridzin  Test. 

The  administration  of  phloridzin  leads,  as  a  rule,  to  temporary  glyco- 
suria. This  glycosuria  appears  fifteen  to  thirty  minutes  after  the 
administration  of  the  drug,  and  disappears  usually  after  three  hours. 
After  the  urine  has  begun  to  run  well  through  the  ureteral  catheter, 
twenty  minims  of  a  i  per  cent,  phloridzin  solution  (freshly  prepared) 
are  given  by  intramuscular  injection. 

Delay  in  the  appearance  of  the  sugar,  or  small  quantities  of  it,  is 
supposed  to  point  to  an  insufficiency  of  the  kidney.  The  more  renal 
parenchyma  present,  the  more  sugar  is  excreted,  since  the  phloridzin,  by 
irritating  them,  causes  the  withdrawal  of  sugar  from  the  blood.  This 
method  is  also  reliable  only  in  a  positi^'e  sense,  because  researches  have 
proved  that  sometimes  absolutely  normal  kidneys  do  not  show  the  sugar 
reaction.  It  is  of  value  when  combined  with  ureteral  catheterizaion. 
The  employment  of  tliis  method  seems  to  involve  a  certain  risk,  as  there 
are  a  few  cases  reported  in  w^hich  the  administration  of  phloridzin  was 
followed  by  hematuria  or  unusually  prolonged  glycosuria. 

All  of  the  previously  enumerated  methods  have  in  common  one 
serious  drawback.  They  do  not  furnish  us  any  clue  as  to  whether  an 
existing  reduction  in  the  functional  capacity  of  a  kidney  is  not  a  tem- 
porary condition  due  to  the  toxic  substances  brought  into  the  circulation 
from  the  other,  i.  e.,  diseased  kidney. 

Electric  Conductivity  of  Urine. 

An  attempt  has  been  recently  made  to  estimate  the  functional  capa- 
city of  a  kidney  by  determining  the  fluctuations  in  the  electric  resistance 
of  the  urine  produced  by  running  indigo-carmJn  through  the  kidneys. 

The  principle  is  this,  that  first  the  electric  conductivity  of  the  urine 
is  tested;  immediately  afterward  indigo-carmin  is  injected  into  the 
gluteal  muscles,  and  the  electric  conductivity  is  again  tested  half  an  hour 


THE   NEWER   METHODS   OF   DIAGNOSIS   OF   RENAL   LESIONS.  749 

after  this  administration.  It  is  claimed  that  diseased  kidneys  show 
a  decidedly  decreased  electric  resistance  after  this  application,  and  it 
is  furthermore  claimed  that  any  decrease  beyond  twenty  ohms  classifies 
such  a  kidney  as  a  surgically  unreliable  one. 

Healthy  kidneys  show  an  increase  in  electric  resistance  varying  up 
to  ten  ohms  after  the  stain  appears  in  the  urine.  Healthy  Iddneys,  only 
temporarily  reduced  in  their  functional  capacity,  which  reduction  is 
proved  by  any  of  the  above  mentioned  methods,  show  nevertheless 
their  normal  possibihties  by  an  increase  of  electric  resistance  after 
administration  of  indigo-carmin. 


INDEX. 


Abdomen,  231 

affections  of,  acute,  245 

pain  as  early  symptom,  256 
suppuration  as  early  symptom,  246 
condition  of,  in  intussusception,  282 
examination  of,  in  enterostenosis,  342 
in  intestinal  strangulation,  280 
in  volvulus,  280 
recti  muscles  of,  suppuration  in,  231 
tumors  of,  285 

arising  from  pelvic  viscera  of  female, 

323 
auscultation  in,  289 
due  to  inflammatory  exudates,  320 
due  to  tuberculous  peritonitis,  320 
having  origin  in  pelvic  viscera  or  bones, 

323 
history,  285 

inflation  of  stomach  or  colon  in,  289 
inspection  in,  287 
occurring   in    corresponding   locations, 

285  _ 
palpation  in,  288 
percussion  in,  289 

results   obtained   from   abdominal   ex- 
amination and  its  adjuncts,  286 
Abdominal  aorta  and  branches,  abdominal 
tumors  due  to  aneurysms  of, 
.321 
differential  diagnosis,  322 
viscera,  injuries  of,  237 

general  condition  of  patient,  238 
history  and  mode  of  accident,  237 
internal  hemorrhage  in,  244 
local  signs,  239 
symptoms,  240 
wall,  affections  of,  231 

congenital  conditions  of,  235 
desmoids  of,  233 

differential  diagnosis,  234 
fibroma  of,  233 
furuncles  of,  231 
inflammatory  affections  of,  231 
injuries  of,  237 
lipoma  of,  233 
pigmented  nevi  of,  233 
jetromuscular  suppuration  in,  231 
suppuration  in,  231 
tumors  of,  233 
Abscess,  cerebral,  otitic,  83 

discharging  through  umliilicus,  236 
epidural,  56,  80 
extradural,  80 
extrasphincteric,  352 
formation,  leukocytosis  in,  721 


Abscess  in  Pott's  disease,  688 
intrasphincteric,  352 

left  subphrenic  in  ulcer  of  stomach,  334 
multiple,  of  omentum,  255 
of  brain,  57,  82 

acute  traumatic,  58 

and  tumor  of  brain,  differentiation,  80 

chronic  traumatic,  59 

irritation  and  paralytic  symptoms,  83 

optic  neuritis  in,  83 

symptoms  of,  focal,  83 
general,  82 
of  cerebellum,  symptoms,  83 
of  superior  rectal  space,  352 
perisinuous,  80 
peritonsillar,  190 
prevesical,  232 
pulmonary,  213 
single,  248 
subphrenic,  253 

differential  diagnosis,  254 
temporo-sphenoidal,  83 
tropical,  248 

differential  diagnosis,  248 
Acetabulum,  fractures  of,  497 
Achondroplasia,  591 
Acid    intoxication,    hepatic,    postoperative, 

703 
Acromegaly,  592 

tumor  of  pituitary  body  causing,  79 
Actinomycosis,   ileocecal,   inflammatory  tu- 
mors of  intestine  from,  307 

of  face,  97 

of  jaws,  120 

of  lungs,  216 

of  neck,  161 

of  pleura,  216 

of  thoracic  wall,  202 
Adenocarcinoma    of    sweat    or    sebaceous 

glands  of  extremities,  557 
Adenocystoma,  benign,  of  testicle,  399 
Adenoma  of  sweat  and  sebaceous  glands  of 
extremities,  556 
of  face,  99 

thyroid,  186 
Adhesions,  perigastric,  in  ulcer  of  stomach, 

335 
Adynamic  ileus,  2S3 

differential  diagnosis,  283 
Air  embolism   in   injuries  of  veins  of  neck, 

.    ^54         . 

in  tissues  in  fracture  of  Ijase  of  skull,  27 
Air-passages,  foreign  bodies  in,  156,  220 
Albuminuria     after    fracture     of     base    of 

skull,  34 


751 


752 


INDEX. 


Alimentary  canal,  injuries  of,  free  fluid  in 
peritoneal  cavity  in,  241 
obliteration  of  liver  dullness  in,  241 
symptoms,  240 
tympanites  in,  241 
vomiting  in,  240 
Anemia,  pernicious,  examination  of  blood 

in,  728 
Aneur3-sm,  arteriovenous,  of  scalp,  69 
cirsoid,  of  extremities,  558 
of  face,  99 
of  scalp,  68 
false,  431 

non-traumatic,  of  larger  vessels  of  extremi- 
ties, 559 
of   abdominal   aorta   and   branches,    ab- 
dominal tumors  due  to,  321 
differential  diagnosis,  322 
of  extremities,  558 
of  subclavian  artery,  153 
thoracic,  207 
traumatic,  431 
of  face,  99 
of  neck,  152 
of  scalp,  69 
Angina  Ludovici,  124 

sclerotica  abdominis,  276 
Angioma  of  face,  98 

of  muscles  of  extremities,  572 
of  salivary  glands,  142 
of  scalp,  68 
cavernous,  68 
Angle,  carrjdng,  474 
Ankle-joint,  diseases  of,  644 
dislocations  at,  516 

in  lateral  direction,  517 
in  sagittal  section,  516 
or  near,  516 
injuries  in  vicinity  of,  513 
tuberculosis  of,  645 

differential  diagnosis,  645 
Ankylosis  of  temporo-maxillary  joint,  122 
Anthrax  complicating  wounds,  543 
edema  complicating  wounds,  543 
Anuria  in  renal  calculus,  370 
Anus,  atresia  of,  346 
fissure  of,  354 
fistula  of,  353 
pruritus  of,  349 
Aorta,   abdominal,   and  branches,   abdom- 
inal tumors  due  to  aneurysms 
of,  321 
differential  diagnosis,  322 
Aphasia,  motor,  47 
sensory,  48 
visual,  48 
Apoplectiform  attacks  in  brain  tumors,  76 
Apoplexy,  late  traumatic,  53 
Appendicitis,  256 
chronic,  341 

differential  diagnosis,  260 
leukocytosis  in,  259,  721 
in  differentiating,  722 
pain  in,  256 
pulse  in,  258 
temperature  in,  259 


Appendicitis,     tenderness     and     muscular 
rigidity  in,  257 

tumor  in,  260 

vomiting  in,  257 
Appendix,  vermiform,  hernia  of,  in  inguinal 

hernia,  409 
Armor-like  cancer,  230 
Arteries,  injuries  of,  429 

of  extremities,  diseases  of,  557 

of  neck,  injuries,  152 
Arteriovenous  aneurysm  of  scalp,  69 
Arteritis  of  extremities,  557 
Artery,  carotid,  injury  of,  152 

middle  meningeal,  hemorrhage  from,  48, 

subclavian,  aneurj^sm  of,  153 

injury  of,  152 
vertebral,  injur}'  of,  152 
Arthritis,  602 

acute,  of  extremities,  579 

traumatic,  604 
chronic,  611 

of  temporo-maxillary  joint,  122 
deformans,  615 

differential  diagnosis,  617 

general  progressive  form,  616 

Heberden's  nodes  in,  615 

in  children  and  young  individuals,  617 

monarticular  form,  616 

of  spine,  691 

polyarticular  form,  616 

vertebral  form,  616 
due  to  syringomyelia,  624 
due  to  tabes,  622 
following  infectious  diseases,  608 
gonorrheal,    609.     See    also    Gonorrheal 

arthritis. 
gouty,  618 

acute,  618 

atypical  or  irregular  form,  619 

chronic,  618 
neurogenica,  622 
neuropathic,  621 
pneumococcus,  608 
primary     acute,      of    temporo-maxillary 

joint,  122 
secondary  acute,  606 
by  extension,  610 
of  temporo-maxillary  joint,  122 

to  pus  foci  elsewhere,  607 
syphilitic,  619 

acquired,  619 

chronic,  619 

hereditary,  620 

secondary,  619 

tertiary,  619 
tabetica,  622 
traumatic,  450 

diagnosis  shortly  after  injury,  452 

free  bodies  in  joints  in,  455 

locking  of  joint  in,  455 

rupture  of  ligaments  in,  453 

subluxation  of  cartilages  in,  453 
tvphoidal,  608 
urica,  618 
Arthropathie  tabetic[ue,  622 


INDEX. 


753^ 


Ascites,  318 

Aseptic  fever,  postoperative,  700 
Asphyxia,  traumatic,  196 
Astragalus,  dislocation  of,  518 

fractures  of,  520 
Atresia  ani,  346 
et  recti,  346 

recti,  346 
Atrophy,  syphilitic,  of  tongue,  133 
Auditory  nerve,  injury,  in  fracture  of  base 

of  skull,  30 
Auscultation  in  empyema,  210 

in  tumors  of  abdomen,  289 

Back,  furuncles  on,  201 

ulcerations  on,   in  tertiary  syphilis,   201 
Bacterial  infections,  effect  on  opsonic  index, 

719    _ 
Balanitis,  385 
Barlow's  disease,  591 

Bile-duct,  common,  gallstones  in,  337,  340 
Bile-passages,  infection  of,  leukocytosis  in, 

722 
Bladder,  371 

abnormal  communication  of,  cystoscopy 
in,  744 

calculus  of,  375 
cystoscopy  in,  741 

congenital  malformations,  371 

distended,  323 

ectopia  of,  371 

edema  of,  cystoscopy  in,  740 

examination  of,  in  renal  calculus,  370 

exstrophy  of,  371 

hemorrhoids  of,  cystoscopy  in,  746 

hernia  of,  in  inguinal  hernia,  407 

inflammation  of,  372.     See  also  Cystitis. 

injuries  of,  symptoms,  243 

lesions  of,  361 

clinical  picture,  361 
examination  of  urine  in,  361 
objective  examination  in,  362 

leukoplakia  of,  cystoscopy  in,  744 

parasites  of,  cystoscopy  in,  743 

rupture  of,  in  fractures  of  pelvis,  491 

syphilis  of,  cystoscopy  in,  744 

tuberculosis  of,  374 

cystoscopy  in,  739 

tuberculous  catarrh  of,  cystoscopy  in,  739 

tumors  of,  376 
cystoscopy  in,  742 

ulcers  of,  cystoscopy  in,  739 

wounds  of,  372 
Blastomycotic  disease  of  face,  95 

ulcers  of  extremities,  546 
Blood,  cryoscopy  of,  747 

escape  of,  from  ear,  nose,  and  mouth   in 
fracture  of  base  of  skull,  27 

examination  of,  715 
in  leukemia,  728 
in  pernicious  anemia,  728 

in  pyemia  complicating  wounds,  540 

in  septicemia  complicating  wounds,  537 
Blood-counting     apparatus,    Thoma-Zeiss, 

716 
Blood-cysts  of  neck,  177 


Blood-pressure  in  acute  peritonitis,  731 
in  collapse,  730 
in  hemorrhage,  730 
in  injuries  of  head,  51,  730 
in  shock,  730 

in  surgical  accidents  and  diseases,  730 
cases,  729 
operations,  730 
increased,  in  brain  tumors,  75 
Blood-vessels,  injuries  of,  429 
in  dislocations,  456 
in  fractures,  443 

of  base  of  skull,  32 
subcutaneous,  198 
Bones,  contusions  of,  438 
cranial,  contusions  of,  61 
injuries  of,  422 

general  considerations  upon,  438 
of  extremities,  benign  tumors  of,  594 
carcinoma  of,  601 
cysts  of,  594 
diseases  of,  575 
acute,_575,  577 
chronic,  575,  582 
enchondroma  of,  596 
endothelioma  of,  601 
exostoses  of,  595 
injuries  of,  438 
myeloma  of,  601 
perithelioma  of,  594,  601 
sarcoma  of,  597.     See  also  Sarcoma  of 

hones  0}  extremities. 
syphilis  of,  584,  585 

acquired,  586 
tuberculosis  of,  582 
tumors  of,  593 
Bow-legs,  654 

Brachial  plexus,  injuries  of,  155,  437 
Brain,  abscess  of,  57,  82.     See  also  Abscess 
of  brain. 
areas,  localization,  44 
compression  of,  36 
first  stage,  37 
fourth  stage,  39 
from  infection  of  meninges  or  brain,  or 

tumors  of  brain,  37 
from  intracranial  hemorrhage,  36 
from  splinters  of  depressed  fracture,  36 
second  stage,  37 

stage  of  advanced  compression,  38 
of  compensation,  37 
of  incipient  or  mild  compression,  37 
of  paralysis,  39 
third  stage,  38 
concussion  of,  35 

stage  of  depression,  35 
of  irritation,  36 
contusion  of,  42 
diseases  of,  73 
injuries  of,  17 

differential  diagnosis,  54 
in  fracture  of  skull,  34 
suppuration  following,  55 
laceration  of,  42 
motor  region,  tumors  of,  76 
tumors  of,  75 


754 


INDEX. 


Brain,  tumors  of,  apoplectiform  attacks  in, 
76 
choked  disc  in,  75 
compression  from,  37 
general  convulsions  in,  76 
headache  in,  75 
increased  blood-pressure  in,  75 
mental  symptoms  in,  75 
optic  neuritis  in,  75 
slow  pulse  in,  75 
symptoms,  focal,  76 

general,  75 
tenderness  of  skull  in,  76 
vertigo  in,  76 
vomiting  in,  75 
venous  sinuses  of,  hemorrhage  from,  49, 

5.3 

vs^hite  matter  of,  lesions,  47 
Branchial  cyst,  174 

fistula,  147 
Breast,  caking  of,  222 

carcinoma  of,  228.     See  also  Carcinoma 
of  breast. 

diffuse  fibroadenoma  of,  224 
fibroma  of,  223 

diseases  of,  221 

fibroadenoma  of,  227 

hypertrophy  of,  227 

inflammatory  processes  of,  221 

sarcoma  of,  228 

tuberculosis  of,  225 

tumors  of,  227 
benign,  227- 

differential  diagnosis,  230 
malignant,  228 
Brenner's  ureter-cystoscope,  737 
Bronchi,  foreign  bodies  in,  156 
Bronchiectasis,  213 
Brown-Sequard  paralysis,  666 
Bulla,  formation  of,  in  fractures,  442 
Bursa,  injuries  of,  428 

of  extremities,  diseases  of,  566 

thyrohyoid,  177 
Bursitis,  acute,  of  extremities,  566 

chronic,  of  extremities,  566 

syphilitic,  of  extremities,  567 

tuberculous,  of  extremities,  567 

Cachexia  in  malignant  tumors  of  kidney, 

317 
Caking  of  breast,  222 
Calculus  in  bladder,  cystoscopy  in,  741 
renal,  365 

anuria  in,  370 

disturbances  in  micturition  in,  369 

examination  of  bladder  in,  370 

of  ureters  in,  370 
hematuria  in,  368 
pain  in,  367 

radiographic  examination  in,  369 
results  of  palpation  in,  367 
urinary  changes  in,  367 
salivary,  125,  140 
vesical,  375 
Callus  formation,  delayed,  in  fractures,  445 
Caput  obstipum,  150 


Carbuncle  of  neck,  160 
Carcinoma,  armor-like,  230 
en  cuirasse,  230 
leukocytosis  in,  725 
of  bones  of  extremities,  601 
of  breast,  228 

age  in,  228 

complications,  230 

condition     of     nipple     and     regional 
lymph-nodes,  229 

edema  of  hand  in,  230 

location  and  growth,  229 

mobility,  consistency,  and  form,  229 

paraplegia  dolorosa  in,  230 
of  duodenum,  308 
of  face,  100 
of  floor  of  mouth,  126 
of  intestine,  308 

condition  of  bowel  movements  in,  309 

differential  diagnosis,  309 

symptoms  of  stenosis  in,  308 

tumor  in,  309 
of  jaws,  115 
of  larynx,  191 
of  lips,  108 
of  liver,  296 
of  neck,  181 

primary,  181 

secondary,  181 
of  parotid  gland,  145 
of  rectum,  359 
of  scalp,  69 
of  stomach,  335 

hemorrhage  in,  335 

pain  in,  335 

tumor  in,  336 

vomiting  in,  335 
of  tongue,  134 

differential  diagnosis,  135 
Carotid  artery,  injury  of,  152 

internal,  intracranial  portion,  injuries, 
hemorrhage  from,  50 
body,  sarcoma  of  neck  arising  from,  180 
sheath,  sarcoma  of  neck  arising  from,  180 

space,  suppuration  in,  159 
Carpal  bones,  dislocations  of,  483 

fractures  of,  483 
Carpo-metacarpal  dislocations,  484 
Carrying  angle,  474 
Cartilages,  costal,  fractures  of,  194 

subluxation  of,  in  traumatic  arthritis,  453 
Catarrh,  tuberculous,  of  bladder,  cystoscopy 

in>  739 
Catheterization,  ureteral,  732 

in  tuberculosis  of  kidney,  365 
Cauda  equina,  lesions  of,  676 
Cellulitis,     emphysematous,     complicating 
wounds,  534 
of  finger  or  hand,  complicating  wounds, 

531 
Cephalhematoma,  18 
Cephalhydrocele,  traumatic,  19 
Cephalic  tetanus,  541 
Cerebellum,  abscess  of,  symptoms,  83 

lesions  of,  48 

tumors  of,  77 


INDEX. 


755 


Cerebral  abscess,  otitic,  83 

localization,  44 

sinus,  thrombosis  of,  84 
Cerebrospinal  fluid,  cytodiagnosis  of,  731 
escape  of,  in  fracture  of  base  of  skull,  28 

meningitis,  cytodiagnosis  in,  731 
Cervical  rib,  148 
Chancre  of  lip,  105 

of  tongue,  130 
Charcot  knee-joints,  620 
Cheeks,  tumors  of  inside  of,  127 
Chest,  193.     See  also  Thorax. 
Choked  disc  in  brain  tumors,  75 
Cholecystitis,  acute,  246 

differential  diagnosis,  247 

phlegmonous,  247 
Chondrodystrophia  foetalis,  591 
Chondroma  of  jaws,  113 

of  neck,  178 
Chondrosarcoma  of  parotid  gland,  144 
Chromocystoscopy,  746 
Circulatory    complications,     postoperative, 

710 
Circumflex  nerve,  injuries  of,  435 
Cirsoid  aneurysm  of  extremities,  558 
of  face,  99 
of  scalp,  68 
Claudication,  intermittent,  551 
Clavicle,  dislocations  of,  464 

at  acromioclavicular  joint,  464 
of  sternal  end,  464 

fractures  of,  462 
Claw-hand,  436 
Club-foot,  656 
Club-hand,  661 
Coeliac  parotitis,  141,  713 
Colic,  gallstone,    264.     See    also    Gallstone 
colic. 

in  enterostenosis,  342 

renal,  270 

symptoms  of,  270 
Collapse,  blood-pressure  in,  730 

postoperative,  699 
CoUes'  fracture,  482 
Colon,  inflation  of,  in  tumors  of  abdomen, 

289 
Coma  and  compression  of  brain,  differen- 
tiation, 40 
Compression  of  brain,  36.     See  also  Brain, 

Compression  of. 
Concussion  of  brain,  35 
stage  of  depression,  35 
of  irritation,  36 

of  spine,  683 
Constipation  in  enterostenosis,  342 

in  intestinal  obstruction,  277 
strangulation,  280 

in  volvulus,  280 
Contraction,  Dupuytren's,  573 
Contracture,    ischemic    muscular,    of    ex- 
tremities, 571 
Contused  wounds  of  scalp,  18 

in  infants  and  young  children,  18 
in  older  children  and  adults,  20 
Contusions,  cerebral,  42 

of  bones,  438 


Contusions  of  cranial  bones,  61 
of  hip,  498 
of  muscles,  424 
of  urethra,  380 
simple,  effect  on  skin,  423 
Convolutions,   ascending  frontal  and  pari- 
etal, lesions  of,  44 
general,  in  brain  tumors,  76 
Corset  liver,  291 

differential  diagnosis,  292 
Costal  cartilages,  fractures  of,  194 
Coxa  vara,  648 

attitude  of  limb,  650 
differential  diagnosis,  651 
gait  and  pain,  651 
history,  650 

limitation  of  motion,  650 
shortening,  650 
symptoms,  650 
traumatica,  499 
jc-ray  examination,  651 
Coxitis,  631 

tuberculous,  632.     See  also  Tuberculosis 
of  hip-joint. 
Cranial  bones,  contusions  of,  61 
Craniotabes,  70 
Crepitus  in  fractures,  447 
Crisis,  Dietl's,  271,  312 

differential  diagnosis,  271 
visceral,  274 
Cryoscopy,  747 

apparatus  for,  747 
Curvature,  lateral,  of  spine,  690 
Cutaneous  tissue,  infection  of,  complicating 

wounds,  531 
Cut-throat,  156 
Cyanosis  in  penetrating  injuries  of  thorax, 

200 
Cystadenoma  of  jaws,  no 
Cystic  disease  of  liver,  295 

duct,  gallstones  in,  340 
.  goiter,  177 
lymphangioma,  congenital,  of  neck,  176 
mastitis,  chronic,  223 
tumors  behind  rectum,  695 

of  neck,  174 
ulcers,  cystoscopy  in,  739 
Cystitis,  372 
acute,  372 

general  symptoms,  373 

painful    and    increased    frequency    of 

urination  in,  372 
sensation  of  weight  and  tenderness  in, 

373. 
urine  in,  373 

chronic,  373 

cystoscopy  in,  738 

differential  diagnosis,  374 

diphtheritic,  373 

nodular  and  ulcerative  tuberculous,  cys- 
toscopy in,  739 

tuberculous  parenchymatous,  cystoscopy 

in,  739 
Cystoscopes,  Nitze's,  737 
Cystoscopic  examination  in  tuberculosis  of 
kidney,  365 


756 


INDEX. 


Cystoscopy,  736 

in  abnormal  communication  of  bladder, 

744 
in  calculi  in  bladder,  741 
in  cystitic  ulcers,  739 
in  cystitis,  738 
in  edema  of  bladder,  740 
in  hemorrhoids  of  bladder,  746 
in  hypertrophy  of  prostate,  740 
in  leukoplakia  of  bladder,  744 
in    nodular    and    \ilcerative    tuberculous 

cystitis,  739 
in  parasites  of  bladder,  743 
in  patent  urachus,  744 
in  syphUis  of  bladder  wall,  744 
in  tuberculosis  of  bladder,  739 
in  tuberculous  catarrh  of  bladder,  739 

parenchymatous  cystitis,  739 
in  tumors  of  bladder  wall,  742 
in  ulcers  of  bladder,  739 
Cysts,  blood,  of  neck,  177 
branchial,  174 
dentigerous,  of  jaws,  108 
dermoid,  of  extremities,  556 

of  face,  99 

of  floor  of  mouth,  126 

of  neck,  178 

of  scalp,  67 
hydatid,  in  muscles  of  extremities,  572 

of  liver,  294 

differential  diagnosis,  294 
suppurating,  254 

of  neck,  177  ' 

of  spleen,  306 
lymph,  of  extremities,  564 
of  accessory  thyroids  and  parathyroids, 

177 
of  bones  of  extremities,  594 
of  mesentery,  310 
of  pancreas,  301 

differential  diagnosis,  302 
of  salivary  ducts,  142 

glands,  142 
retention-,  of  salivary  glands,  141 
sebaceous,  of  extremities,  556 

of  face,  99 

of  neck,  178 
thyroglossal,  126,  176 
unilocular,  of  neck,  177 
Cytodiagnosis,  731 

of  cerebrospinal  fluid,  731 

meningitis,  731 
of  pleural  fluids,  732 
of  tuberculous  meningitis,  731 

Deafness,  word-,  48 

Decubital  ulcers  of  extremities,  548 

of  tongue,  128 
Defence  musculaire,  240 
Deformities  caused  by  anterior  poliomyeli- 
tis, 654 

congenital,  of  hands,  661 

in  dislocations,  459 

in  fractures,  447 

in  Pott's  disease,  687 

of  extremities,  646 


Delirium,  traumatic,  528,  529 
in  fractures,  444 
tremens,  528,  529 
in  fractures,  444 
Dental  ulcers,  128 
Dentigerous  cysts  of  jaws,  108 
Dermoid  cysts  of  extremities,  556 
of  face,  99 

of  floor  of  mouth,  126 
of  neck,  178 
of  scalp,  67 
sequestration,  sacrococcygeal,  695 
Descent,  imperfect,  of  testicle,  388 
complications,  388 
hernia  and  hydrocele  in  connection 

with,  391 
inflammation  in,  389 
tumor  formation  in,  389 
Desmoids  of  abdomen,  233 
differential  diagnosis,  234 
of  muscles  of  extremities,  572 
Diabetic  complications,  postoperative,  712 

gangrene  of  extremities,  551 
Diaphragm,  penetrating  wounds  of,  201 

subcutaneous  injuries  of,  197 
Diaphragmatic  hernia,  421 
Dietl's  crisis,  271,  312 

differential  diagnosis,  271 
Digestion,  disturbances  of,  leukocytosis  in, 

723 
Digits,  supernumerary,  661 
Dilatation,  idiopathic,  of  esophagus,  330 
of  stomach,  331,  332 

from  acquired  stenosis  of  pylorus,  332 

from  congenital  stenosis  of  pylorus,  331 

postoperative,  706 
Diphtheritic  cystitis,  373 
Dislocations  at  ankle-joint,  516 

in  lateral  direction,  517 

in  sagittal  section,  516 
carpo-metacarpal,  484 
change  in  length  of  limb  in,  461 
congenital,  of  hip,  646 

differential  diagnosis,  647 

of  extremities,  646 

of  knee,  648 

of  patella,  648 

of  shoulder,  648 
deformity  in,  459 
diagnosis  in  general,  458 
disturbance  of  function  of  limb  in,  461 
general  considerations  on,  456 
habitual,  456 
injury  of  blood-vessels  in,  456 

of  nerves  in,  457 
■     near  ankle,  516 

objective  signs  of,  459 
of  astragalus,  518 
of  carpal  bones,  483 
of  clavicle,  464 

at  acromioclavicular  joint,  464 

of  sternal  end,  464 
of  hip,  496 
of  jaw,  90 
of  knee,  506 

backward,  506 


INDEX. 


757 


Dislocations  of  knee,  forward,  506 
of  metacarpal  bones,  486 
of  metatarsal  bones,  523 
of  patella,  505 
of  phalanges,  486 
of  radius,  478 
and  ulna,  477 
backward,  478 
of  shoulder-joint,  470 
backward  forms,  472 
subspinous  forms,  472 
of  shoulder  region,  461 
of  spine,  679 

pathology,  664 
of  tendons,  427 
of  toes,  524 
of  ulna  and  radius,  477 

backward,  478 
of  vertebrae,  679 
pathology,  664 
of  wrist,  484 
pathologic,  456 
recurrent,  456 
special,  461 
subacromial,  472 
subastragaloid,  518 
subclavicular,  472 
subcoracoid,  objective  signs,  471 
subglenoid,  symptoms  of,  472 
tibiotarsal,  516 
^-ray  examination  in,  461 
Displacement,  congenital,  of  kidney,  311 
Distended  bladder,  323 
Diverticula  of  esophagus,  177,  329 

of  pharynx,  177 
Drug  eruptions,  postoperative,  712 
Drugs,  poisoning  from,  postoperative,   712 
Dullness  in  flanks  and  right  iliac  region  in 
perforating  ulcers  of  stomach  and  duo- 
denum, 267 
liver,  obliteration  of,  in  perforating  ulcers 
of  stomach  and  duodenum,  266 
Duodenal    ulcer,    332.     See    also    Ulcer   of 

stomach. 
Duodenum,  cancer  of,  308 

ulcer  of,  332.     See  also  Ulcer  of  stomach. 
perforating,  266.     See  also  Ulcer,  per- 
forating, of  duodenum. 
Dupuytren's  contraction,  573 
Dyspeptic  symptoms  in  ulcer  of  stomach, 

333 
Dyspnea  in  penetrating  injuries  of  thorax, 

200 

Ear,  escape  of  blood  from,  in  fracture  of 
base  of  skull,  27 

middle,    suppuration    from,    intracranial 
complications,  80 
Echinococcus  cysts.     See  Hydatid  cysts. 
Ectopia  testis,  388 

vesicae,  371 
Edema,  anthrax,  complicating  wounds,  543 

malignant,  complicating  wounds,  534 

of  bladder,  cystoscopy  in,  740 

of  glottis,  190 

of  hand  in  cancer  of  breast,  230 


Edema,  pulmonary,  in  fractures,  444 
Elbow,  miner's,  567 

pulled,  479 

sprains  of,  473 
Elbow-joint,  injuries  in  vicinity  of,  478 

tuberculosis  of,  628 
Electric  conductivity  of  urine,  748 
Elephantiasis,  554 
Eleventh  nerve,  injury,  in  fracture  of  base 

of  skull,  31 
Embolic  gangrene  of  extremities,  552 
Embolism,  air,  in  injuries  of  veins  of  neck, 

fat,  in  fractures,  443 

in  fractures,  442 

of  mesenteric  vessels,  272 

differential  diagnosis,  273 

postoperative,  710 

pulmonary,  postoperative,  702 
Emphysematous       cellulitis       complicating 

wounds,  534 
Empyema,  208 

auscultation  in,  210 

causes,  208 

clinical  course,  209 

differential  diagnosis,  210 

exploratory  puncture  in,  210 

history,  209 

in  penetrating  injuries  of  thorax,  200 

inspection  in,  209 

metapneumonic,  208 

of  joints,  tuberculous,  612 

palpation  in,  209 

percussion  in,  209 

physical  examination  in,  209 

tuberculous,  208 
Enchondroma  of  bones  of  extremities,  596 

of  ribs,  207 
Endothelioma  of  bones  of  extremities,  601 
Enlargement  of  cervical  lymph-nodes,  163. 
See  also  Lymph-nodes  of  neck,  enlarge- 
ment. 

of  kidney,  diseases  accompanied  by,  313 
in  renal  tuberculosis,  365 

of  lips,  104 

of  prostate,  377 

differential  diagnosis,  378 

of  spleen,  305 
Enterocele,  acute  partial,  404 
Enterostenosis,  341 

colic  in,  342 

condition  of  feces  in,  342 

constipation  in,  342 

examination  of  abdomen  in,  342 

history  in,  342 

peristalsis  in,  342 

tympanites  in,  342 
Epidermal  infection  complicating   wounds, 

531 
Epididymis,  tumors  of,  399 
Epididymitis,  gonorrheal,  392 
Epidural  abscess,  56,  80 
Epilepsy,  traumatic,  62 
Epiphyseal  separation  of  femur  in  children, 

500 
Epiphysitis  of  extremities,  580 


758 


INDEX. 


Epispadias,  379 

Epithelioma  of  extremities,  557 

of  face,  loi 

of  lips,  107 

of  penis,  386 
Epulis,  112 
Eruptions,  drug,  postoperative,  712 

postoperative,  711 
Erysipelas  complicating  wounds,  535 

facial,  92 

leukocj'tosis  in,  721 

of  scalp,  66 
Er\'sipeloid  complicating  wounds,  536 
Esophagus,  diseases  of,  324 

diverticulum  of,  177,  329 

foreign  bodies  in,  330 

methods  of  examination,  331 

idiopathic  dilatation  of,  330 

stricture  of,   324.     See  also  Stricture   of 
esophagus. 

subcutaneous  injuries  of,  198 
Examination,  methods  of,  715 
Exophthalmic  goiter,  189 

Moebius'  symptom  of,  189 
Stell wag's  symptom  of,  189 
von  Graefe's  symptom  of,  189 
Exostoses  of  bones  of  extremities,  595 
Exploratorv'  puncture  in  empyema,  210 
Exstrophy  of  bladder,  371 
Extradural  abscess,  80 
Extrasphincteric  abscess,  352 
Extra-uterine  pregnancy,  rupture  of,  284 
Extremities,  422 

diseases  of,  544 
of  skin,  554 

and  subcutaneous  tissues,  544 

lower,  infection  in,  complicating  wounds, 

534 
tumors  of  skin  and  subcutaneous  tissue, 

555 
Exudates,  inflammator}',  abdominal  tumors 
due  to,  320 

Face,  actinomycosis  of,  97 
angioma  of,  98 
benign  tumors  of,  98 
blastomycotic  disease  of,  95 
bones  of,  fractures,  87 

injuries,  87 
carcinoma  of,  100 
cirsoid  aneurysms  of,  99 
dermoid  cysts  of,  99 
epithelioma  of,  10 1 
erv'sipelas  of,  92 
fibroma  molluscum  of,  99 
furuncles  of,  94 
injuries  and  diseases  of,  86 
lipoma  of,  99 
lupus  of,  95 

malignant  tumors  of,  100 
neoplasms  of,  98 
sarcoma  of,  loi 
sebaceous  cysts  of,  99 

glands,  adenoma  of,  99 
soft  parts,  diseases  of,  92 
infections  of,  92 


Face,  soft  parts,  injuries  of,  86 
sweat  glands,  adenoma  of,  99 
S}'phLlis  of,  96 
traumatic  aneur\'sms  of,  99 
Facial  ner\"e,  injur}'  of,  139 

in  fracture  of  base  of  skull,  28 
Facies  in  perforating  ulcers  of  stomach  and 

duodenum,  267 
False  aneur}-sm,  431 
Fasciae  of  extremities,  diseases  of,  573 
Fat  embolism  in  fractiires,  443 
Feces,  condition  of,  in  enterostenosis,  342 

examination  of,  732 
Feet,  foreign  bodies  in,  661 
Felon,  532 
Femoral  hernia,  414 

differential  diagnosis,  415 
Femur,  epiphyseal  separation,  in  children, 
500 
fractures  of,  500 
of  head,  497 
of  lower  end,  503 
of  neck,  493 

in  children,  499 
of  shaft,  501 
Ferment  fever,  postoperative,  700 
Fetal  rickets,  591 
Fever  in  gallstone  colic,  264 

in  intussusception,  282 
Fibroadenoma,  diffuse,  of  breast,  224 

of  breast,  227 
Fibroma,  diffuse,  of  breast,  223 
molluscum  of  face,  99 
of  abdomen,  233 
of  jaws.  III 
of  neck,  179 
of  salivar}-  glands,  142 
of  scalp,  68 
of  thorax,  206 
Fibula,  fractures  of  lower  end,  514 
of  upper  end,  509 
isolated  fractures  of  upper  and  middle 
thirds  of  shaft,  512 
Finger,  cellulitis  of,  complicating  wounds, 

Finger-joints,  diseases  of,  629 
Fingers,  webbed,  661 
Fissure  of  anus,  354 
Fistula,  branchial,  147 
in  ano,  353 
salivar}',  139 
thyroglossal,  147 
Flat-foot,  657 
Floating  kidney,  312 

differential  diagnosis,  313 
.  liver,  293 

differential  diagnosis,  293 
spleen,  304 
Foreign  bodies  in  air  passages,  156,  220 
in  bronchi,  156 
in  esophagus,  330 

methods  of  examination,  331 
in  feet,  661 
in  hands,  661 
in  rectum,  348 
in  trachea,  156 


INDEX. 


759 


Foreign  bodies,  intestinal  obstruction  from, 

282 
Fossa,  individual,  of  base  of  skull,  fracture, 

32 
middle,  of  skull,  tumors  of,  78 
Fourth  nerve,  injury,  in  fracture  of  base  of 

skull,  30 
Fractures,  438 

abnormal  mobility  of  bone  in,  447 
associated  with  fragilitas  ossium,  441 

with  general  diseases,  441 

with  idiopathic  friability  of  bone,  441 

■with  local  lesions  of  bone,  441 

with  osteoporosis,  441 
closed,  439 
CoUes',  482 
complete,  438,  439 
complicated,  439 
complications  of,  442 
compound,  439 
crepitus  in,  447 
deformity  in,  447 
delayed  callus  formation  in,  445 

union  in,  445 
delirium  tremens  in,  444 
diagnosis  in  general,  446 
displacement  of  fragments,  440 
embolism  in,  442 
fat  embolism  in,  443 
faulty  union  in,  446 
fibrous  union  in,  445 
formation  of  bullae  in,  442 
greenstick,  of  radius  and  ulna,  480 
gunshot,  439 
healing  of,  442 
history  in,  446 

in  sarcoma  of  bones  of  extremities,  600 
incomplete,  438,  439 
injury  to  blood-vessels  in,  443 

to  nerves  in,  443 
intercondyloid,  of  lower  end  of  humerus, 
.474 
isolated,  of  upper  and  middle  thirds  of 

shaft  of  fibula,  512 
longitudinal,  439 
loss  of  function  of  limb  in,  448 
mal-union  in,  446 
number  of  fragments,  440 
objective  signs  of,  447 
oblique,  439 
of  acetabulum,  497 
of  astragalus,  520 
of  bones  of  face,  87 
of  carpal  bones,  483 
of  clavicle,  462 
of  costal  cartilages,  194 
of  femur,  500 
of  great  trochanter,  498 
of  head  and  neck  of  radius,  477 

of  femur,  497 
of  hyoid  bone,  155 
of  inferior  maxilla,  89 
of  larynx,  155 
of  lower  end  of  fibula,  514 
of  humerus,  473 


Fractures  of   lower  end    of   humerus,  epi- 
physeal separation,  475 
of  external  epicondyle  and  exter- 
nal condyle,  476 
of  internal  epicondyle  or  internal 
condyle,  476 
of  radius,  482 
of  tibia,  514 
of  lower  jaw,  89 
of  lumbar  vertebrae,  678 
of  malar  bone,  88 
of  metacarpal  bones,  486 
of  metatarsal  bones,  522 
of  nasal  bones,  87 
of  neck  of  femur,  493,  503 

in  children,  499 
of  OS  calcis,  521 
of  patella,  505 
of  pelvis,  488 

abnormal  mobility  in,  489 
pain  in,  489 

rupture  of  bladder  in,  491 
of  urethra  in,  490 
of  phalanges,  486 

of  toes,  522 
of  ribs,  193 

signs  due  to  fracture  alone,  193 

due  to  injury  of  intrathoracic  viscera, 
194 
of  scapula,  465 
of  shaft  of  femur,  501 
of  humerus,  472 
of  radius,  479 
of  tibia,  510 
of  ulna,  479 
of  shoulder  region,  461 
of  skull,  22 

at  later  period,  26  • 
depressed,  24 

compression  of  brain  from  splinters, 

36 
of  vertex,  25 
examination  of  vertex,  23 

where  no  scalp  wound  is  present, 

23 
where  wound  of  scalp  exists,   25 
fissured,  25 

history  of  mode  of  injury,  22 
intracranial  symptoms,  34 
of  base,  27 

albuminuria  after,  34 
escape  of  blood  from  ear,  nose,  and 
mouth,  27 
of  cerebrospinal  fluid,  28 
glycosuria  after,  34 
hemorrhage    or   presence    of   air   in 

tissues,  27 
injury  of  auditory  nerve,  30 
of  facial  nerve,  28 
of  hypoglossal  nerve,  31 
of  nerves,  28 
of     ninth,     tenth,    and     eleventh 

nerves,  31 
of  olfactory  nerve,  30 
of  optic  nerve,  30 


6o 


INDEX. 


Fractures  of  skull,  of  base,  injury  of  third, 
fourth,  and  sixth  nerves,  30 
of  trigeminal  nerve,  31 
of  twelfth  nerve,  31 
of  vessels,  32 
of  individual  fossae,  32 
of  both  tables,  26 
of  external  table,  25 
of  internal  table,  26 
punctured,  25 
of  spine,  676 

from  third   cervical  to   second   dorsal 
vertebra,  677 
to  twelfth  dorsal  vertebrae,  678 
of  atlas  and  axis,  676 
of  upper  two  cervical  vertebrae,  676 
pathology,  664 
of  sternum,  194 
of  superior  maxilla,  88 
of  surgical  neck  of  humerus,  469 
of  tarsal  bones,  519 
of  trachea,  155 
of  upper  end  of  fibula,  509 
of  humerus,  466 

epiphyseal  separation,  468 
of  anatomic  neck,  467 
of  radius,  477 
of  tibia,  506 
of  ulna,  477 
of  upper  jaw,  88 
open,  439    _ 
osteomyelitis  in,  443 
pain  in,  448 
pathologic,  439,  441 
pertrochanteric,  of  Kocher,  498 
pneumonia  in,  444 
Pott's,  514 

pseudarthrosis  in,  445 
pulmonary  edema  in,  444 
seat  of,  440 

septic  complications  in,  443 
simple,  439 
special,  461 
spiral,  439 
spontaneous,  441 
subjective  signs  of,  448 
subperiosteal,  441 
supracondyloid,  of  humerus,  474 
T,  of  lower  end  of  humerus,  474 
thrombosis  in,  442 
transverse,  439 
traumatic  delirium  in,  444 
union  with  deformity  in,  446 
vicious  union  in,  446 
a:-ray  examination  in,  449 
Y,  of  lower  end  of  humerus,  474 
Fragilitas  ossium,  fracture  associated  with, 
-    441 
Free  bodies  in  joints  in  traumatic  arthritis, 

455 
Frontal  convolution,  ascending,  lesions  of, 
44 
lobe,  lesions  of,  47 
tumors  of,  76 
Frost-bite,  gangrene  of  extremities  from,  552 
Furuncles  of  abdomen,  231 


Furuncles  of  back,  201 
of  face,  94 
of  neck,  160 

Gallbladder,  gallstones  in,  339 
hydrops  of,  297 

infection  of,  leukocytosis  in,  722 
malignant  disease  of,  298 
region,  palpation  of,  in  gallstones,  339 
ttunors  of,  297 

differential  diagnosis,  298 
Gallstone  colic,  264 

differential  diagnosis,  264 
fever  in,  264 
jaundice  in,  264 
muscular  rigidity  in,  264 
pain  and  tenderness  in,  264 
vomiting  in,  264 
Gallstones,  337 

diagnosis  in  interval,  338 

of  location,  if  arrested  temporarily  or 
permanently,  339 
differential  diagnosis,  337 
history,  338 

in  common  duct,  337,  340 
in  cystic  duct,  340 
in  gallbladder,  339 
leukocytosis  in,  724 
palpation  of  gallbladder  region  in,  339 
physical  examination  in,  339 
Ganglion  of  extremities,  570 
Gangrene  of  extremities,  548 
diabetic,  551 
dry,  549 
embolic,  552 
from  frost-bite,  552 
from  injury  to  arteries  or  veins  of  limb, 

552 
from  Raynaud's  disease,  553 
in  infectious  diseases,  552 
moist,  549 
pre-senile,  551 
senile,  551 
pulmonary,  213 
Gangrenous  stomatitis,  123 
Gastro-intestinal  tract,  diseases  of,  leuko- 
cytosis in,  723 
Genito-urinary    tract,     lower    portion    of, 
localization  of  pus  in,  381 
instrumental  examination  for, 

383 
two-glass  test  for,  381 
urethroscop}-  for,  384 
Genu  valgum,  653 

varum,  654 
Gibbus  in  Pott's  disease,  688 
Glanders  complicating  wounds,  543 
Glossitis,  acute,  128,  129 

chronic,  129 
Glottis,  edema  of,  190 

Glycosuria  after  fracture  of  base  of  skull,  34 
Goiter,  179,  185 
cystic,  177 

exophthalmic,  189.     See  also  Exophthal- 
mic goiter. 
fibrous,  186 


INDEX. 


761 


Goiter,  lingual,  137 
malignant,  187 
non-malignant,  185 
retrosternal,  187 
simple  parenchymatous,  185 
vascular,  186 
Gonitis,  tuberculous,  641.      See  also  Tuber- 
culosis of  knee-joint. 
Gonorrheal  arthritis,  609 
phlegmonous,  609 
purulent,  609 
serofibrinous,  609 
articular  hydrops,  609 
epididymitis,  392 
orchitis,  392 
peritonitis,  acute,  250 
Gouty  arthritis,  618 
acute,  618 

atypical  or  irregular  form,  619 
chronic,  618 
Graefe's  symptom  in  exophthalmic  goiter, 

189 
Granulation-tissue  tumors  of  jaws,  iii 
Granuloma  of  jaws,  in 
Greenstick  fractures  of  radius  and  ulna,  480 
Gumma  of  lips,  106 
Gummatous    osteomyelitis   of    extremities, 

587 
periostitis  of  extremities,  587 
Gunshot  fractures,  439 
wounds  of  spine,  684 

Habitual  dislocation,  456 

Hallux  valgus,  661 

Hands,  cellulitis  of,  complicating  wounds, 

congenital  deformities,  661 

edema  of,  in  cancer  of  breast,  230 

foreign  bodies  in,  661 
Harelip,  103 
Head,  affections,  17 

injuries  of,  blood-pressure  in,  730 

tetanus,  541 
Headache  in  brain  tumors,  75 

in  purulent  leptomeningitis,  81 
Heart,  diseases  of,  postoperative,   702 

penetrating  injuries  of,  200 

subcutaneous  injuries  of,  198 
Heberden'-S  nodes   in   arthritis    deformans, 

Hemangioma  of  extremities,  556 

of  neck,  176 
cavernous,  176 

of  tongue,  133 
Hemangiosarcoma  of  extremities,  557 
Hematcmesis,  postoperative,  706 
Hematomyelia,  681 
Hematorachis,  681 
Hematuria  in  malignant  tumors  of  kidney, 

315 

in  renal  calculus,  368 
Hemophilia,  433 
Hemophiliac  joints,  624 
Hemorrhage,  525 

blood-pressure  in,  730 

characteristic  signs  of,  525 


Hemorrhage,    compression  of   brain   from, 

36 
concealed,  postoperative,  697 
external,  postoperative,  697 
from   injuries  of  intracranial  portion  of 

internal  carotid  and  vertebral  arteries, 

from  middle  meningeal  artery,  48 

from  smaller  arteries  of  pia  arachnoid,  49 

from  venous  sinuses  of  brain,  49,  53 

in  cancer  of  stomach,  335 

in  fracture  of  base  of  skull,  27 

in  scalp,  location,  18 

in  ulcer  of  stomach,  333 

intermeningeal,  49,  52 

internal,  early  signs  of,  284 

in  injuries  of  abdominal  viscera,  244 

postoperative,  697 
intracranial,  48 
middle  meningeal,  48,  50 
postoperative,  696 
subdural,  52 
Hemorrhoids,  355 

of  bladder,  cystoscopy  in,  746 
Hemothorax    in     penetrating    injuries     of 

thorax,  199 
Hepatoptosis,  293 
Hernia,  401 
cerebri,  62 
diaphragmatic,  421 
femoral,  414 

differential  diagnosis,  415 
in  connection  with  imperfect  descent  of 

testicle,  391 
incarcerated,  402 
inflamed,  402 
inguinal,  404 

differential  diagnosis,  409 

direct,  406 

hernia  of  bladder  in,  407 
of  ovary  in,  409 
of  vermiform  appendix  in,  409 

indirect,  405 

interstitial,  407 

oblique,  405 

straight,  406 

unusual  contents  of,  407 
Littre's,  404 
lumbar,  421 
obstructed,  402 
obturator,  421 

of  bladder  in  inguinal  hernia,  407 
of  muscles,  427 

of  ovary  in  inguinal  hernia,  409 
of  vermiform  appendix  in  inguinal  hernia, 

409 
pulmonary,  207 
rarer  forms  of,  421 
sciatic,  421 
strangulated,  403 
umbilical,  417 

congenital,  417 

in  adults,  418 

infantile,  417 
ventral,  420 
Herpes  of  lips,  104 


76: 


IXDEX. 


Hip,  congenital  dislocations  of,  646 
differential  diagnosis,  647 
contusion  of,  498 
dislocation  of,  496 
injuries  of,  492 
in  children,  498 
Hip-joint,  diseases  of,  631 

tuberculosis  of,  632.     See  also  Tuhercu- 
losis  0}  hip-joint. 
Hodgkin's  disease,  enlargement  of  cervical 

lymph-nodes  in,  166 
Hour-glass  stomach  in  ulcer  of  stomach,  334 
Housemaid's  knee,  567 
Humerus,  fractures  of  lower  end,  473 
epiphyseal  separation,  475 
intercondyloid,  474 
of  external  epicondyle  and  external 

condyle,  476 
of  internal  epicondyle  or  internal 
condyle,  476 
of  shaft,  472 
of  surgical  neck,  469 
supra condj'loid  fracture  of,  474 
T-fractures,  of  lower  end,  474 
upper  end,  fractures  of,  466 

epiphyseal  separation,  468 
of  anatomic  neck,  467 
Y-fractures,  of  lower  end,  474 
Hydatid  cysts  in  muscles  of  extremities,  572 
of  liver,  294 

differential  diagnosis,  294 
suppurating,  254 
of  lungs,  216. 
of  neck,  177 
of  skull,  72 
of  spleen,  306 
Hydrocele    in    connection    with    imperfect 

descent  of  testicle,  391 
Hydrocephalocele,  71 
Hydrocephalus,  73 
Hydronephrosis,  313 

differential  diagnosis,  314 
Hydrophobia  complicating  wounds,  542 
Hydrophobic  tetanus,  541 
Hydrops,  articular,  tuberculous,  611 
of  gallbladder,  297 
of  joints,  chronic,  614 
gonorrheal,  609 
intermittent,  605,  614 
Hyoid  bone,  fractures  of,  155 
Hyperleukocytosis,  720 
Hypertrophy  of  breasts,  227 

of  prostate,  cystoscopy  in,  740 
Hypoglossal   ner^'e,   injur}',   in   fracture   of 

base  of  skull,  31 
Hypospadias,  379 
Hysteria,  postoperative,  714 
Hysterical  joints,  626 
spine,  692 

Icterus,  postoperative,  703 

Ileocecal   actinomycosis,   inflammatory   tu- 
mors of  intestine  from,  307 
tuberculosis,     inflammatory     tumors     of 
intestine  from,  307 

Ileus,  277 


Ileus,  adynamic,  283 

differential  diagnosis,  283 
postoperative,  707 
Incarcerated  hernia,  402 
Index,  opsonic,  719 
abnormal,  719 

effect  of  bacterial  infections  on,  719 
phagocytic,  of  leukocyte,  718 
Infection  along  tendon-sheaths    complicat- 
ing wounds,  532 
between  muscles  and  tendons  of  forearm 

and  arm  complicating  wounds,  532 
epidermal,  complicating  wounds,  531 
hepatic,  248 
in  lower  extremities  complicating  wounds, 

.534 

in  wounds  of  upper  extremities,  530 
intracranial,    follov^-ing    injury,    differen- 
tial diagnosis,  61 
of   cutaneous   and   subcutaneous   tissues 

complicating    wounds,  531 
of  lymph-nodes  of  scalp,  66 
of  male  reproductive  organs,  391 
of  scalp,  65 
postoperative,  700 
renal,  251 

subungual,  complicating  wounds,  532 
ungual,  complicating  wounds,  532 
Infectious  diseases,  arthritis  following,  608 
gangrene  of  extremities  in,  552 
leukocytosis  in,  720 
Inflamed  hernia,  402 

Inflammation,    acute,    of    lymph-nodes    of 
extremities,  565 
of  neck,  162 
chronic,   of  Ivmph-nodes  of  extremities, 

566 
of  bladder,  372.     See  also  Cystitis. 
of  intra-abdominal  portion  of  vas  defer- 
ens, 276 
of  testicle  in  imperfect  descent,  389 
Inflammatory  exudates,  abdominal  tumors 
due  to,  320 
processes  of  rectum  and  results,  349 
Inflation  of  stomach  or  colon  in  diagnosis 

of  tumors  of  abdomen,  289 
Inguinal    hernia,    404.     See    also   Hernia, 

inguinal. 
Inspection  in  tuberculous  coxitis,  632,  633 
in  tumors  of  abdomen,  287 
of  rectum,  345 
Instrumental    examination   for   localization 

of  pus  in  genito-urinary  tract,  383 
Intermittent  claudication,  551 
Intestinal  obstruction,  277 
acute,  277 

chronic,  341.     See  also  Enterostcnosis. 
constipation  in,  277 
early  signs  of,  277 
examination  of  abdomen  in,  280 
from  foreign  bodies,  282 

history  of,  282 
from  tumors,  282 
history  of,  282 
leukocytosis  in,  723 
pain  in,  278 


INDEX. 


763 


Intestinal  obstruction,  probable  nature  and 
seat  of,  279 
symptoms  of,  277 
vomiting  in,  278 
strangulation,  279 
constipation  in,  280 
history  of,  279 
nausea  in,  280 
pain  in,  279 
shock  in,  280 
vomiting  in,  280 
Intestine,  carcinoma  of,  308 

condition  of  bowel  movements  in,  309 
differential  diagnosis,  309 
symptoms  of  stenosis  in,  308 
tumor  in,  309 
evacuation  of,  in  intussusception,  282 
neoplasms  of,  308 
tumors  of,  307 

inflammatory,  307 

from  ileocecal  actinomycosis,  307 
from  tuberculosis,  307 
Intoxication,    acid,    hepatic    postoperative, 

703 
Intrasphincteric  abscess,  352 
Intussusception,  281 

condition  of  abdomen  in,  282 

evacuation  of  bowels  in,  282 

fever  in,  282 

meteorism  in,  282 

nausea  in,  282 

pain  in,  281 

previous  history,  281 

prostration  in,  282 

tenesmus  in,  282 

tumor  in,  282 

vomiting  in,  282 

Jaundice  in  gallstone  colic,  264 
Jaw,  dislocation  of,  90 
lower,  fractures  of,  89 
upper,  fractures  of,  88 
Jaws,  actinomycosis  of,  120 

acute  suppurative  osteomyelitis  of,  121 

carcinoma  of,  115 

chondroma  of,  113 

cystadenoma  of,  no 

dentigerous  cysts  of,  108 

diseases  of,  108 

fibroma  of,  in 

granulation-tissue  tumors  of,  in 

granuloma  of,  in 

infections  of,  117 

following  compound  fractures,  119 

from  teeth,  nS 
odontoma  of,  109 
osteoma  of,  no 
phosphorus  necrosis  of,  121 
sarcoma  of,  113 
syphilis  of,  120 
tuberculosis  of,  119 
tumors  of,  108 

benign,  108 

malignant,  113 
Joints,   acute   rheumatism  of,   leukocytosis 

in,  721 


Joints,  chronic  rheumatism  of,  618 

diseases  of,  601 

examination  of  joint,  603 
general  condition  of  patient,  603 
history  of  case,  603 

empyema  of,  tuberculous,  612 

free  bodies  in,  in  traumatic  arthritis,  455 

hemophiliac,  624 

hydrops  of,  chronic,  614 
gonorrheal,  609 
intermittent,  605,  614 
tuberculous,  611 

hysterical,  626 

injuries  of,  422 

general  considerations  upon,  450 

lipoma  of,  626 

neuralgic,  626 

of  extremities,  injuries  of,  438 

rheumatism  of,  acute,  605 

scorbutic,  624 

tuberculosis  of,  611.     See  also  Tubercu- 
losis of  joints. 

tumors  of,  626 

Keloid  of  extremities,  555 
Kidney,  calculus  in,  365.     See  also  Calcu- 
lus, renal. 
colic  of,  270 

symptoms,  270 
congenital  displacement  of,  311 

malformations  of,  312 
diseases  of,  newer  methods  of  diagnosis, 

732 
postoperative,  709 
enlargement  of,  diseases  accompanied  by; 
313 
in  tuberculosis  of  kidney,  365 
floating,  312 

differential  diagnosis,  313 
in  pyemia  complicating  wounds,  539 
in  septicemia  complicating  wounds,  537 
infections  of,  251 
injury  of,  symptoms,  241 
lesions  of,  361 

clinical  picture,  361 
examination  of  urine  in,  361 
objective  examination  in,  362 
malignant  tumors  of,  315 
cachexia  in,  317 
hematuria  in,  315 
metastases  in,  317 
pain  in,  316 
tumors  in,  316 
metastatic  suppuration  of,  252 
movable,  312 

differential  diagnosis,  313 
neoplasms  of,  314 

differential  diagnosis,  318 
polycystic,  314 

differential  diagnosis,  314 
tuberculosis  of,  363.     See  also  Titiercn- 

losis  of  kidney. 
tumors  of,  3 1 1 
Knee,  dislocations  of,  506 
backward,  506 
forward,  506 


764 


INDEX. 


Knee,  housemaid's,  567 
Knee-joint,  Charcot,  620 

congenital  dislocation  of,  648 

diseases  of,  639 

injuries  in  vicinity  of,  504 

tuberculosis  of,  641.     See  also  Tubercu- 
losis of  knee-joint. 
Knock-knee,  653 
Kocher's  pertrochanteric  fracture,  498 

Laceration  of  brain,  42 
Lachrymal  and  salivary  glands,  symmetri- 
cal disease  of,  98 
Larynx,  carcinoma  of,  191 
fractures  of,  155 
papilloma  of,  190 
Leg,  varicose  ulcers  of,  545 
Leptomeningitis,  purulent,  56,  81 
headache  in,  81 
optic  neuritis  in,  81 
pulse  in,  81 
respiration  in,  81 
Leukemia,  examination  of  blood  in,  728 
lymphatic,  enlargement  of  cervical  lymph- 
nodes  in,  164 
Leukocyte-count,  differential,  715 
value  of,  725 

in  differential  diagnosis,  726 
Leukocytes,  phagocytic  index  of,  718 
Leukocytosis,  720 

in  abscess  formation,  721 
in  acute  articular  rheumatism,  721 
in  appendicitis,. 259,  721 
in  differentiating,  722 
in  carcinoma,  725 

in  diseases  of  gastro-intestinal  tract,  723 
of  nervous  system,  724 
of  pancreas,  724 
of  urinary  system,  724 
in  disturbances  of  digestion,  723 
in  duodenal  ulcer,  723 
in  erysipelas,  721 
in  gallstones,  724 
in  gastric  ulcer,  723 

in  infection  of  gallbladder  and  bile-pas- 
sages, 722 
of  serous  membranes,  723 
in  infectious  diseases,  720 
in  intestinal  obstruction,  723 
in  malignant  disease,  724 
in  meningitis,  721 
in  osteomyelitis,  723 
in  pelvic  peritonitis,  722 
in  pneumonia,  720 
in  salpingitis,  722 
in  sarcoma,  725 
in  scarlet  fever,  721 
in  septicemia,  721 
in  surgical  conditions  of  liver,  723  ' 
in  syphilis,  728 
in  tuberculosis,  727 
in  typhoid  fever,  720 
pathologic,  720 
physiologic,  720 
Leukoma,  129 
Leukopenia,  720 


Leukoplakia,  129 

of  bladder,  cystoscopy  in,  744 
Ligaments,  rupture  of,  in  traumatic  arthri- 
tis, 453 
Lingual  goiter,  137 

tonsil,  138 
Lipoma  arborescens,  626 

at  floor  of  mouth,  126 

of  abdominal  wall,  233 

of  face,  99 

of  joints,  626 

of  neck,  178 

of  salivary  glands,  143 

of  scalp,  67 

of  thorax,  206 

of  tongue,  133 
Lips,  104 

carcinoma  of,  108 

chancre  of,  105 

enlargement  of,  104 

epithelioma  of,  107 

gumma  of,  106 

herpes  of,  104 

malformations  of,  103 

ulcerations  of,  105 
Litigation  symptoms,  683 
Littre's  hernia,  404 
Liver,   acid  intoxication  of,   postoperative, 

703 
carcinoma  of,  296 
corset,  291 

differential  diagnosis,  292 
cystic  disease  of,  295 
diseases  of,  postoperative,  703 
dullness,   obliteration   of,   in   injuries   of 
alimentary  canal,  241 
in  perforating  ulcers  of  stomach  and 
duodenum,  266 
floating,  293 

differential  diagnosis,  293 
hydatid  cysts  of,  294 

differential  diagnosis,  294 
infections  of,  248 
sarcoma  of,  296 

suppurating  echinococcus  cysts  of,  254 
surgical  conditions  of,  leukocytosis  in,  723 
syphilis  of,  296 
tumors  of,  291 
malignant,  296 

differential  diagnosis,  297 
Localization,  cerebral,  44 

spinal,  666 
Locking  of  joint  in  traumatic  arthritis,  455 
Lockjaw,  122,  540.     See  also  Tetanus. 
Lumbar  hernia,  421 

puncture,  determining  point  for,  52 

method  of  performing,  53 
vertebrae,  fractures  of,  678 
Lungs,  abscess  of ,  213 
actinomycosis  of,  216 
echinococcus  of,  216 
edema  of,  in  fractures,  444 
embolism  of,  postoperative,  702 
gangrene  of,  213 
hernia  of,  207 
postoperative  complications  of,  701 


INDEX. 


765 


Lungs,  prolapse  of,  in  penetrating  injuries 
of  thorax,  200 
subcutaneous  injuries  of,  196 
tumors  of,  217 
Lupus  of  face,  95 
Luschka's  gland,  sarcoma  of  neck  arising 

from,  180 
Lymphangioma,  congenital  cystic,  of  neck, 
176 
of  extremities,  556 
of  face,  100 
of  tongue,  134 
Lymphangiosarcoma  of  extremities,  557 
Lymphangitis,  acute,  of  extremities,  563 

chronic,  of  extremities,  564 
Lymphatic  leukemia,  enlargement  of  cer- 
vical lymph-nodes  in,  164 
Lymph-cysts  of  extremities,  564 
Lymph-nodes  of  extremities,  acute  inflam- 
mation of,  565 
chronic  inflammation  of,  566 
diseases  of,  565 
of  neck,  acute  inflammation,  162 
affections,  162 
enlargement,  163 
carcinomatous,  167 
in  lymphatic  leukemia,  164 
in  lymphosarcoma,  165 
in  pseudo-leukemia,  166 
simple  hyperplastic,  172 
syphilitic,  168 
tuberculous,  169 
of  scalp,  infection,  66 
pelvic,  neoplasms  of,  323 
Lymphosarcoma,   enlargement    of    cervical 

lymph-nodes  in,  165 
Lymph-vessels  of  extremities,  diseases  of, 
563 

Macrolabia,  104 
Main  en  griffe,  436 
Mai  perforans  pedis,  546 
Maladie  cystique,  223 
Malar  bone,  fractures  of,  88 
Malformations,  congenital,  of  bladder,  371 
of  kidney,  312 
of  neck,  147 
of  penis,  379 
of  rectum,  346 
of  urethra,  379 
in  connection  with  urachus,  236 
of  lips,  103 

of  neck,  acquired,  147 
congenital,  147 
Mal-union  in  fractures,  446 
Mastitis,  acute  puerperal,  221 
chronic,  223 
cystic,  223 
interstitial,  224 
neonatorum,  223 
traumatic,  223 
Mastoid  suppuration,  intracranial  compli- 
cations of,  80 
Maxilla,  inferior,  fractures  of,  89 

superior,  fractures  of,  88 
Median  nerve,  injury  of,  437 


Mediastinum,  affections  of,  218 
inflammatory  processes  of,  218 
tumors  of,  219 

Medulla,  lesions  of,  48 

Meningeal  artery,  hemorrhage  from,  48 

Meninges,  infection,  compression  of  brain 
from,  37 

Meningitis,  cerebrospinal,  cytodiagnosis  in, 

731 
leukocytosis  in,  721 
serous,  82 

tuberculous,  cytodiagnosis  in,  731 
Meningocele,  71,  662 

spuria  traumatica,  19 
Mental  disturbances  following  cranial  in- 
jury, 64 
in  pyemia  complicating  wounds,  539 
in  septicemia  complicating  wounds,  537 
symptoms  in  brain  tumors,  75 
Mesenteric  vessels,  embolism  of,  272 
differential  diagnosis,  273 
thrombosis  of,  272 

differential  diagnosis,  273 
Mesentery,  cysts  of,  310 

tumors  of,  310 
Metacarpal  bones,  dislocations  of,  486 

fractures  of,  486 
Metapneumonic  empyema,  208 
Metatarsal  bones,  dislocations  of,  523 

fractures  of,  522 
Metatarsalgia,  660 
Meteorism  in  intussusception,  282 
Microstomia,  104 

Micturition,  disturbances  in,  in  renal  calcu- 
lus, 369 
painful  and  increased  frequency  of,    in 
acute  cystitis,  372 
Middle  ear  suppuration,  intracranial  com- 
plications of,  80 
Mikulicz's  disease,  98 
Miner's  elbow,  567 
Mobility,  abnormal,  in  fractures  of  pelvis, 

489 
Moebius'  symptom  of  exophthalmic  goiter, 

189 
Moles  on  extremities,  556 
pigmented,  of  scalp,  68 
of  thorax,  206 
Molluscum  fibrosum  of  face,  99 
Morton's  disease,  660 
Motor  aphasia,  47 

region  of  brain,  tumors  of,  76 
Mouth,  diseases  of,  103,  123 

escape  of  blood  from,  in  fracture  of  base 

of  skull,  27 
floor  of,  carcinoma  of,  126 
dermoid  cysts  at,  126 
diagnosis  of  conditions  at,  124 
lipoma  at,  126 
injuries  of,  123 
syphilis  of,  124 
Movable  kidney,  312 

differential  diagnosis,  313 
Mucous  patches  on  tongue,  131 
Mummification  of  extremities,  549 
Mumps,  140 


766 


INDEX. 


Muscles    and    tendons     of    forearm     and 
arm,    infection    between,  complicating 
wounds,  532 
contusions  of,  424 
hernia  of,  427 
injuries  of,  424 

of  extremities,  angioma  of,  572 
desmoids  of,  572 
diseases  of,  570 
hydatid  cysts  in,  572 
inflammatory  affections,  570 
sarcoma  of,  572 
tumors  of,  572 
penetrating  wounds  of,  428 
rupture  of,  426 
Muscular  contracture,  ischemic,  of  extrem- 
ities, 571 
paralysis  of  extremities,  571 
rheumatism,  acute,  of  extremities,  570 
rigidity  in  appendicitis,  257 
in  gallstone  colic,  264 
in  perforating  ulcers  of   stomach    and 
duodenum,  266 
Musculospiral  nerve,  injuries  of,  435 
Myelocele,  662 
Myelocystocele,  662 
Myeloma  of  bones  of  extremities,  601 
Myelomeningocele,  662 
Myoma,  large,  of  uterus,  324 
Myositis,  acute  serous,  of  extremities,  570 
suppurative,  of  extremities,  571 
fibrous,  of  extremities,  571 
ossificans  of  extremities,  571 
sclerosing,  of  extremities,  571 
simple  chronic,  of  extremities,  571 
syphilitic,  of  extremities,  571 
traumatic  ossifying,  425 
tuberculous,  of  extremities,  571 

Nasal  bones,  fractures  of,  87 

deformity  due  to  syphilis,  98 

septum,  injuries  of,  87 
Nausea  in  intestinal  strangulation,  280 

in  intussusception,  282 

in  ulcer  of  stomach,  333 

in  volvulus,  280 
Neck,  actinomycosis  of,  161 

affections  of,  147 

arteries  of,  injuries,  152 

blood-cysts  of,  177 

carbuncle  of,  160 

carcinoma  of,  181 
primary,  181 
secondary,  181 

chondroma  of,  178 

cystic  tumors  of,  174 

dermoid  cysts  of,  178 

echinococcus  cysts  of,  177 

fibroma  of,  179 

furuncle  of,  160 

hemangioma  of,  176 
cavernous,  176 

inflammatory  processes  in,  157 

injuries  of,  152 

lipoma  of,  178 

lymphangioma  of,  congenital  cystic,    176 


Neck,  lymph-nodes  of,  acute  inflammation, 
162 

affections,  162 

enlargement,    163.     See   also   Lymph- 
nodes  of  neck,  enlargement. 
malformations  of,  acquired,  147 

congenital,  147 
nerves  of,  injuries,  154 
osteoma  of,  178 
previsceral  suppuration  in,  158 
sarcoma  of,  179 

arising  from  carotid  body,  180 
sheath,  180 
sebaceous  cysts  of,  178 
solid  tumors  of,  178 
superficial  structures,  infection  of,  160 
traumatic  aneurysms  of,  152 
tumors  of,  172 

auscultation  and  percussion,  174 

classification,  174 

examination,  172 

of  blood,  spleen,  mouth,  and  body 
in  general,  173 

inspection,  172 

palpation,  173 
unilocular  cysts  of,  177 
veins  of,  injuries,  154 
woody  phlegmon  of,  161 
Necrosis,  phosphorus,  of  jaws,  121 
Nerve,  auditory,  injury,  in  fracture  of  base 

of  skull,  30 
circumflex,  injury  of,  435 
eleventh,    injury,   in  fracture   of  base   of 

skull,  31 
facial,  injury  of,  139 
fourth,    injury,    in    fracture    of    base    of 

skull,  30 
hypoglossal,  injury,  in  fracture  of  base  of 

skull,  31 
median,  injury  of,  437 
musculospiral,  injury  of,  435 
ninth,  injury,  in  fracture  of  base  of  skull, 

olfactory,  injury,  in  fracture  of  base  of 

skull,  30 
optic,  injury,  in  fracture  of  base  of  skull, 

3° 
peroneal,  injury  of,  438 

popliteal,  external,  injury  of,  438 

sciatic,  and  branches,  injury  of,  438 

sixth,  injury,  in  fracture  of  base  of  skull, 

3° 
tenth,  injury,  in  fracture  of  base  of  skull, 

31 
third,  injury,  in  fracture  of  base  of  skull, 

3° 
trigeminal,  injury,  in  fracture  of  base  of 

skull,  31 

twelfth,   injury,   in    fracture    of    base    of 

skull,  31 

ulnar,  injury  of,  437 

Nerves,  injuries  of,  433,  435 

in  dislocations,  457 

in  fractures,  443 

of  base  of  skull,  28 

of  extremities,  diseases  of,  573 


INDEX. 


767 


Nerves  of  extremities,  tumors  of,  574 

of  neck,  injuries  of,  154 
Nervous   system,   diseases   of,   leukocytosis 

in,  724 
Neuralgia,  trigeminal,  loi 
Neuralgic  joints,  626 
Neuritis  of  extremities,  573 

optic,  in  abscess  of  brain,  83 
in  brain  tumors,  75 
in  purulent  leptomeningitis,  81 
Neuromata  dolorosa  of  extremities,  574 

multiple,  of  extremities,  575 

traumatic,  of  extremities,  574 
Neuropathic  arthritis,  621 
Nevus,  pigmented,  of  abdomen,  233 
Ninth  nerve,  injury,  in  fracture  of  base  of 

skull,  31 
Nitze's  cystoscopes,  737 
Nodes,  Heberden's,  in  arthritis  deformans, 

615 
Noma,  95,  123 

Nose,  escape  of  blood  from,  in  fracture  of 
base  of  skull,  27 

saddle-,  due  to  syphilis,  97 

Obstructed  hernia,  402 

Obstruction,     intestinal,      277.     See     also 

Intestinal  obstruction. 
Obturator  hernia,  421 
Occipital  lobe,  lesions,  47 

tumors  of,  77 
Odontoma  of  jaws,  109 
Olfactory  nerve,  injury,  in  fracture  of  base 

of  skull,  30 
Omentum,  multiple  abscess  of,  255 
puckering  of,  343 
tumors  of,  310 
Opsonic  index,  719 
abnormal,  719 

effect  of  bacterial  infections  on,  719 
Opsonins,  716 

technic  of  measuring  quantity,  718 
Optic  nerve,  injury,  in  fracture  of  base  of 
skull,  30 
neuritis  in  abscess  of  brain,  83 
in  brain  tumors,  75 
in  purulent  leptomeningitis,  81 
Orchitis,  gonorrheal,  392 
Os  calcis,'fractures  of,  521 

innominatum,  sarcoma  of,  323 
Osteitis  deformans,  592 
Osteoarthropathie  pneumatique,  592 
Osteoma  of  extremities,  595 
of  jaws,  no 
of  neck,  178 
of  skull,  72 
Osteomalacia  of  extremities,  589 

differential  diagnosis,  590 
Osteomyelitis,  acute  infective,  of  extremi- 
ties, 578 
of  ribs,  202 
of  skull,  70 
of  spine,  691 
of  sternum,  203 

suppurative,  of  extremities,  578,  579 
differential  diagnosis,  581 


Osteomyelitis,  acute  suppurative,  of  jaws, 
121 
gummatous,  of  extremities,  587 
in  fractures,  443 
leukocytosis  in,  723 
Osteoporosis,  fracture  associated  with,  441 
Otitic  cerebral  abscess,  83 
Ovary,  hernia  of,  in  inguinal  hernia,  409 
tumors  of,  large,  324 
pedunculated,  324 
torsion  of  pedicle,  273 

differential  diagnosis,  274 

Pachymeningitis    haemorrhagica    interna, 

55 

purulent,  56 
Pain    as    early    sign    of    acute    abdominal 
affections,  256 

in  appendicitis,  256 

in  carcinoma  of  stomach,  335 

in  coxa  vara,  651 

in  fractures,  448 
of  pelvis,  489 

in  gallstone  colic,  264 

in  intestinal  obstruction,  278 
strangulation,  279 

in  intussusception,  281 

in  malignant  tumors  of  kidney,  316 

in    perforating    ulcers    of    stomach    and 
duodenum,  266 

in  Pott's  disease,  687 

in  renal  calculus,  367 

in  tuberculosis  of  joints,  612 
of  kidney,  365 

in  tuberculous  gonitis,  642 

in  ulcer  of  stomach,  332 

in  volvulus,  280 

location  of,  in  tuberculous  coxitis,  636 

referred,  from  spinal   and  thoracic  con- 
ditions, 276 
Palate,  diseases  of,  103 

tumors  of,  127 
Palpation  in  empyema,  209 

in  tuberculous  coxitis,  632,  634 

in  tumors  of  abdomen,  288 

of  gallbladder  region  in  gallstones,  339 

of  rectum,  345 

results  of,  in  renal  calculus,  367 
Pancreas,  diseases  of,  leukocytosis  in,  724 
Pancreatic  cysts,  301 

differential  diagnosis,  302 

neoplasms,  303 

differential  diagnosis,  303 

tumors,  299 
Pancreatitis,  acute,  270 

differential  diagnosis,  270 

chronic,  tumors  due  to,  299 
Papillary  wart  on  extremities,  556 
Papilloma  of  larynx,  190 

of  tongue,  134 
Paralysis,  Brown-Sequard,  666 

muscular,  of  extremities,  571 

pseudo-,  621 
Paraphimosis,  385 

Paraplegia  dolorosa  in  cancer  of  breast,  230 
Parasites  of  bladder,  cystoscopy  in,  743 


768 


INDEX. 


Parathyroid  glands,  accessory,  cysts  of,  177 
Parietal  convolutions,  ascending,  lesions  of, 

44 
lobe,  lesions,  47 
tumors  of,  77 
Parotid  duct,  injuries  of,  139 
gland,  carcinoma  of,  145 
chondrosarcoma  of,  144 
injuries  of,  138 
tumors  of,  145 
Parotitis,  coeliac,  141,  713 

postoperative,  713 
Patella,  congenital  dislocation,  648 
dislocations  of,  505 
fractures  of,  505 
Patent  urachus,  cystoscopy  in,  744 
Patulency  of  ureter,  734 
Pedicles   of   ovarian    and    uterine   tumors, 
torsion,  273 
differential  diagnosis,  274 
Pelvic  lymph-nodes,  neoplasms  of,  323 
peritonitis,  leukocytosis  in,  722 
viscera,  abdominal  tumors  having  origin 

in,  323 
of  female,  tumors  of  abdomen  arising 
from,  323 
Pelvis,  fractures  of,  488 

abnormal  mobility  in,  489 
pain  in,  489 

rupture  of  bladder  in,  491 
of  urethra  in,  490 
Penis,  congenital  malformations  of,  379 
diseases  and  injuries  of,  379 
epithelioma  of,  386 
Percussion  in  empyema,  209 
in  tumors  of  abdomen,  289 
Perforating  ulcers  of  stomach  and  duode- 
num, 266 
differential  diagnosis,  267 
dullness  in  flanks  and  right  iliac 

region  in,  267 
facies  in,  267 
muscular  rigidity  in,  266 
obliteration  of  liver  dullness  in,  266 
pain  in,  266 
pulse  in,  267 
respiration  in,  267 
symptoms,  266 
vomiting  in,  266 
of  typhoid  fever,  268 

differential  diagnosis,  269 
Perforation  in  ulcer  of  stomach,  333 
Pericarditis,  suppurative,  217 
Pericardium,  penetrating  injuries  of,  200 

subcutaneous  injuries  of,  198 
Pericolitis  sinistra,  255 
Perigastric  adhesions  in  gastric  ulcer,  335 
Perinephritis,  251 

differential  diagnosis,  252 
Periosteal  sarcoma  of  ribs,  207 
Periostitis,  acute    infective,    of   extremities, 
578 
of  skull,  70 

traumatic,  of  extremities,  577 
gummatous,  of  extremities,  587 


Perirectal  infection,  350 

phlegmon,  diffuse,  350 
Perisinuous  abscess,  80 
Peristalsis  in  enterostenosis,  342 
Perithelioma  of  bones  of  extremities,  594, 

601 
Peritoneal  cavity,  free  fluid  in,  in  injuries  of 

alimentary  canal,  241 
Peritoneum,  tumors  of,  310 
Peritonitis,  acute,  blood-pressure  in,  731 

gonorrheal,  acute,  250 

pelvic,  leukocytosis  in,  722 

pneumococcus,  250 

postoperative,  708 

primary  forms,  250 

tuberculous,  343 

abdominal  tumors  due  to,  320 
acute,  250 
ascitic  form,  344 

differential  diagnosis,  344 
Peritonsillar  abscess,  190 
Pernicious   anemia,   examination   of  blood 

in,  728 
Peroneal  nerve,  injury  of,  438 
Pertrochanteric  fracture  of  Kocher,  498 
Pes  planus,  657 
Pfeiffer's  disease,  171 
Phagocytic  index  of  leukocyte,  718 
Phagocytosis,  716 
Phalanges,  dislocations  of,  486 

fractures  of,  486 

of  toes,  fractures  of,  522 
Pharynx,  diverticula  of,  177 
Phimosis,  385 
Phlebitis  of  extremities,  561 

postoperative,  711 
Phlegmon,  acute,  of  thoracic  wall,  201 

diffuse  perirectal,  350 

ligneux  of  Reclus,  161 

of  scalp,  66 

woody,  of  neck,  161 
Phlegmonous  cholecystitis,  247 
Phloridzin  test,  748 
Phosphorus  necrosis  of  jaws,  121 
Pia   arachnoid,   hemorrhage   from   smaller 

arteries  of,  49 
Pituitary  body,  tumor  of,  causing  acromeg- 
aly, 79 
Pleura,  actinomycosis  of,  216 

subcutaneous  injuries  of,  196 

tumors  of,  212 
Pleural  fluids,  cytodiagnosis  of,  732 
Plexus,  brachial,  injury  of,  154,  437 
Pneumococcus  arthritis,  608 

peritonitis,  250 
Pneumonia  in  fractures,  444 

in  penetrating  injuries  of  thorax,  200 

leukocytosis  in,  720 

postoperative,  701,  702 
Pneumothorax    in    penetrating    injuries    of 

thorax,  199 
Podagra,  618 

Poisoning  from  drugs,  postoperative,  712 
Poliomyelitis,   anterior,   deformities  caused 

by,  654 


INDEX. 


769 


Polycystic  kidneys,  314 

differential  diagnosis,  314 
Polydactylism,  661 
Polyps  of  rectum,  359 
Pons  varolii,  lesions  of,  47 
Pontomedullocerebellar  space,  tumors  of,  77 
Popliteal  nerve,  external,  injury  of,  438 
Postoperative  complications,  696 

miscellaneous,  711 
Pott's  disease,  6S4 
abscesses  in,  688 
deformity  in,  6S7 
differential  diagnosis,  689 
gibbus  in,  688 
pain  in,  687 
rigidity  of  spine  in,  686 
spinal  cord  symptoms,  689 
fracture,  514 
Pregnancy,  extra-uterine,  rupture  of,  284 
Prevesical  abscess,  232 
Previsceral  suppuration  in  neck,  158 
Proctitis,  349 
acute,  349 
chronic,  349 
hypertrophic,  350 
Prolapse  of  lung  in  penetrating  injuries  of 
thorax,  200 
of  rectum,  356 
Prostate,  affections  of,  377 
enlargement  of,  377 

differential  diagnosis,  378 
hypertrophy  of,  cytoscopy  in,  740 
Prostration  in  intussusception,  282 
Pruritus  ani,  349 
Pseudarthrosis  in  fractures,  445 
Pseudoleukemia,   enlargement    of    cervical 

lymph-nodes  in,  166 
Pseudoparalysis,  621 

syphilitic,  585 
Psoriasis  linguae,  129 
Puckering  of  omentum,  343 
Puerperal  mastitis,  acute,  221 
Pulled  elbow,  479 
Pulse  in  appendicitis,  258 

in    perforating    ulcers    of    stomach    and 

duodenum,  267 
in  purulent  leptomeningitis,  81 
in  pyemia  complicating  wounds,  539 
in  septicemia  complicating  wounds,  537 
slow,  in  brain  tumors,  75 
Puncture,  exploratory,  in  empyema,  210 
lumbar,  determining  point  for,  52 
method  of  performing,  53 
Purulent  leptomeningitis,  56,  81 
headache  in,  81 
optic  neuritis  in,  81 
pulse  in,  81 
respiration  in,  81 
pachymeningitis,  56 
Pus,   localization    of,   in    lower    portion  of 
genito-urinary  tract,  381 
instrumental  examination  in, 

383 
two-glass  test  for,  381 
urethroscopy  for,  384 
Pyelitis,  362 

49 


Pyelonephritis,  251 

differential  diagnosis,  251 
Pyemia  com])licating  wounds,  53S 

differential  diagnosis,  540 
Pylephlebitis,  suppurative,  249 
Pylorus,  stenosis  of,  acquired,  gastric  dila- 
tation from,  332 
congenital,  gastric  dilatation  from,  331 
Pyonephrosis,  252 
Pyopericardium,  217 

Rachioschisis,  662 
Rachitic  rosary,  591 
Rachitis,  590 

Radiographic  examination  in  renal  calcu- 
lus, 369 
Radius  and  ulna,  dislocation  of,  477 
backward,  477 

dislocation  of,  478 

fractures  of  shaft,  479 
of  head  and  neck,  477 
of  lower  end,  482 
of  upper  end,  477 

greenstick  fracture  of,  480 

lesions  of,  473 

subluxation  of,  479 
Railway  spine,  683 
Ranula,  acute,  125 

chronic,  126 
Rashes,  septic,  postoperative,  712 
Raynaud's  disease,  gangrene  of  extremities 

due  to,  553 
Reclus,  phlegmon  ligneux  of,  161 
Rectal  space,  superior,  abscess  of,  352 
Recti  muscles  of  abdomen,  suppuration  in- 

sheath  of,  231 
Rectum,  345 

abnormal  opening  of,  346 

atresia  of,  346 

cancer  of,  359 

circumscribed  suppuration  of,  350 

congenital  malformations  of,  346 

cystic  tumors  behind,  695 

examination  of,  345 

foreign  bodies  in,  348 

history  in  examining,  346 

inflammatory  processes  and  results,  349 

injuries  of,  347 

inspection  of,  345 

neoplasms  of,  359 

palpation  of,  354 

polyps  of,  359 

prolapse  of,  356 

stricture  of,  357 

differential  diagnosis,  358 

ulceration  of,  non-malignant,  354 

use  of  specula  in  examining,  345 
Referred  pain  from  spinal  and  thoracic  con- 
ditions, 276 
Reproductive   organs,   male,   infections  of, 

391      .      . 
Respiration  in  perforating  ulcers  of  stomach 
and  duodenum,  267 

in  purulent  leptomeningitis,  8r 
Retained  testicle,  388 
Retention-cysts  of  salivary  glands,   141 


//' 


IXDEX. 


Retromuscular   suppuration   in   abdominal 

wall,  231 
Rheumatism,  acute  articular,  605 
leukoc}i;osis  in,  721 
of  extremities,  570 
chronic  articular,  618 
Rib,  cervical,  148 
Ribs,  acute  osteomyelitis  of,  202 
enchondroma  of,  207 
fractures  of,  193 

signs  due  to  fractiu^e  proper,  193 

due  to  injur}'  of  intrathoracic  viscera, 
194 
periosteal  sarcoma  of,  207 
secondary,'  tumors  of,  207 
tuberculosis  of,  203 
Rickets,  590 
fetal,  591 
Riva-Rocci  sphygmomanometer,  38 
Rodent  ulcers  of  extremities,  557 
Rosan,-,  rachitic,  591 

Rupture  of  bladder  in  fractures  of  pelvis, 
491 
of  extra-uterine  pregnancy,  284 
of  ligaments  in  traumatic  arthritis,  453 
of  muscles,  426 
of  tendons,  426 
of  urethra,  380 

in  fractures  of  pelvis,  490 

Sacrococcygeal    sequestration    dermoids, 

695 
teratomata,  695 
tumors,  695 
Sacroiliac  joints,  diseases  of,  630 

tuberculosis  of,  630 
Saddle-nose  due  to  syphilis,  97 
Salivary  and  lachr\-mal  glands,  symmetrical 
disease  of,  98 
calculus,  125,  140 
ducts,  cysts  of,  142 
fistula,  139 

glands,  affections  of,  138 
angioma  of,  142 

benign  connective-tissue  tumors  of,  142 
cysts  of,  142 

inflammatory  affections  of,  140 
injuries  of,  138 
fibroma  of,  142 
lipoma  of,  143 
mixed  tumors  of,  143 
retention-cysts  of,  141 
sarcoma  of,  143 

submaxillar}',  solid  tumors  of,  125,  179 
S}'philis  of,  141 
tuberculosis  of,  141 
tumors  of,  141,  142 
Salpingitis,  leukocytosis  in,  722 
Sapremia  complicating  wounds,  536 
Sarcoma,  leukocytosis  in,  725 
of  bones  of  extremities,  597 
differential  diagnosis,  600 
fracture  in,  600 
myelogenous,  599 
periosteal,  599 
primary  forms,  598 


Sarcoma  of  bones  of  extremities,  x-ray  in,  600 

of  breast,  228 

of  extremities,  556 

of  face,  loi 

of  jaws,  113 

of  liver,  296 

of  muscles  of  extremities,  572 

of  neck,  179 

arising  from  carotid  body,  180 
sheath,  180 

of  OS  innominatum,  323 

of  salivary  glands,  143 

of  scalp,  69 

of  skull,  72 

of  spleen,  306 

of  thorax,  206 

of  tongue,  134 

periosteal,  of  ribs,  207 
Scalp,  angioma  of,  68 
cavernous,  68 

arteriovenous  aneur}-sm  of,  69 

carcinoma  of,  69 

cirsoid  aneurysm  of,  68 

contused  wounds  of,  18 

in  infants  and  young  children,  18 
in  older  children  and  adults,  20 

dermoid  cysts  of,  67 

diseases  of,  65 

erysipelas  of,  66 

fibroma  of,  68 

hemorrhages  in,  location,  18 

infection  of,  65 

injuries  of,  17 

lipoma  of,  67 

lymph-nodes  of,  infection,  66 

malignant  tumors  of,  69 

penetrating  wounds  of,  17 

phlegmon  of,  66 

pigmented  moles  of,  68 

sarcoma  of,  69 

traumatic  aneurysm  of,  69 

tumors  of,  66 

vascular  tumors  of,  68 

warts  of,  68 
Scapula,  fractures  of,  465 
Scarlatina,  leukocytosis  in,  721 

postoperative,  711 
Sciatic  hernia,  421 

nerve  and  branches,  injury  of,  43S 
Sclerosing  myositis  of  extremities,  571 
Scoliosis,  690 
Scorbutic  joints,  624 
Scorbutus,  591 
Scurfy,  591 

Sebaceous  cysts  of  extremities,  556 
of  face,  99 
of  neck,  17S 

glands  of  extremities,  adenocarcinoma  of, 

557  , 

adenoma  of,  556 
of  face,  adenoma  of,  99 
Sensory  aphasia,  48 
Septic  complications  in  fractures,  443 

rashes,  postoperative,  712 
Septicemia  complicating  wounds,  537 
differential  diagnosis,  540 


INDEX. 


771 


Septicemia,  leukocytosis  in,  721 
Septicopyemia  complicating  wounds,  538 
Septum,  nasal,  injuries  of,  87 
Sequestration  dermoids,  sacrococcygeal,  695 
Shock,  525 

blood-pressure  in,  730 

characteristic  signs  of,  526 

in  intestinal  strangulation,  280 

in  volvulus,  280 

postoperative,  699 
Shoulder,  congenital  dislocation,  648 

injuries  of,  differential  diagnosis,  460 

region,  dislocations  in,  461 
fractures  in,  461 
Shoulder-joint,  diseases  of,  627 

dislocations  of,  470 
backward,  472 
subspinous  forms,  472 

tuberculosis  of,  628 
Sigmoid  sinus,  thrombosis  of,  85 
Sinus,  cavernous,  thrombosis  of,  85 

cranial,  thrombosis  of,  84 

sigmoid,  thrombosis  of,  85 

thrombosis,  intracranial,  59 
Sinuses,  venous,  of  brain,  hemorrhage  from, 

49,  53 
Sixth  nerve,  injur)',  in  fracture  of  base  of 

skull,  30 
Skin,  injuries  of,  423 
Skull,  acute  osteomyelitis  of,  70 
periostitis  of,  70 

congenital  defects  of,  71 

diseases  of,  69 

echinococcus  of,  72 

fractures  of,   22.     See  also  Fractures  of 
skull. 

injuries  of,  17 

mental  conditions  following,  64 

middle  fossa  of,  tumors  of,  78 

osteoma  of,  72 

sarcoma  of,  72 

syphilis  of,  69 

tenderness  of,  in  brain  tumors,  76 

tuberculosis  of,  69 

tumors  of,  72 
Sounds,  examination  of  ureter  with,  732 
Specula,  use  of,  in  examining  rectum,  345 
Speech  region,  lesions  of,  47 
Spermatic-cord,  torsion  of,  274 
Spermatocele,  399 

Sphygmomanometer,  Riva-Rocci,  38 
Spina  bifida,  662 
Spinal  conditions,  referred  pain  from,  276 

cord  symptoms  of  Pott's  disease,  689 
tumors  of,  692 

localization,  666 
Spine,  acute  osteomyelitis  of,  691 

arthritis  deformans  of,  691 

concussion  of,  683 

cross-lesions  of,   table   of   symptoms   in, 
669-675 

diseases  and  injuries  of,  662,  684 

dislocations  of,  679 
pathology,  664 

fractures  of,  676.     See  also  Fractures  oj 
spine. 


Spine,  gunshot  wounds  of,  684 

hysterical,  692 

injuries  of,  664 
pathology,  664 

lateral  curvature,  690 

raUway,  683 

rigidity  of,  in  Pott's  disease,  686 

stab  wounds  of,  684 

tumors  of,  692 

typhoid,  692 
Spleen,  enlargements  of,  305 

floating,  304 

hydatid  cysts  of,  306 

sarcoma  of,  306 

tumors  of,  304 

wandering,  304 
Spondylitis  deformans,  6gi 

traumatic,  683 

tuberculous,  684.     See  also  Pott's  disease. 
Sprains,  453 

of  elbow,  473 
Sputum,  examination  of,  732 
Stab  wounds  of  spine,  684 
Status  thymicus,  postoperative,  713 
Stellwag's  symptom  of  exophthalmic  goiter, 

189 
Steno's  duct,  wounds  of,  86 
Stenosis  of  pjdorus,  acquired,  gastric  dilata- 
tion from,  332 
congenital,  gastric  dilatation  from,  331 

symptoms  of,  in  cancer  of  intestine,  308 
Sternum,  acute  osteomyelitis  of,  203 

fractures  of,  194 

secondary  tumors  of,  207 

tuber ci-dosis  of,  203 
Still's  disease,  617 

Stomach,  carcinoma  of,  335.     See  also  Car- 
cinoma oj  stomach. 

contents,  examination  of,  732 

dilatation  of,  331,  332 

from  acquired  stenosis  of  pylorus,  332 
from    congenital   stenosis   of    pylorus, 

postoperative,  706 
diseases  of,  postoperative,  704 
hour-glass,  in  ulcer  of  stomach,  334 
inflation  of,  in  tumors  of  abdomen,  289 
surgical  diseases  of,  331 
tumors  of,  289 

differential  diagnosis,  290 
ulcer  of,  332.     See  also  Ulcer  oj  stomach. 
perforating,  266.     See  also  Ulcer,  per- 
jorating,  oj  stomach. 
Stomatitis,  123 
gangrenous,  123 
ulcerative,  123 
Strangulated  hernia,  403 
Strangulation,    intestinal,    279.       See    also 

Intestinal  strangulation. 
Stricture  of  esophagus,  324 
carcinomatous,  328 
cicatricial,  328 
due  to  pressure  from    external    causes, 

328 
methods  of  examination,  325 
spasmodic,  329 


772 


INDEX. 


Stricture  of  rectum,  357 

differential  diagnosis,  358 
of  ureter,  734 
Subacromial  dislocation,  472 
Subastragaloid  dislocations,  518 
Subclavian  artery,  aneurysm  of,  153 

injury  of,  152 
Subclavicular  dislocation,  472 
Subcoracoid  dislocation,  objective  signs,  471 
Subcortical  regions,  lesions  of,  47 
Subcutaneous  tissue,   infection  of,  compli- 
cating wounds,  531 
Subdural  hemorrhage,  52 

suppuration,  56 
Subglenoid  dislocations,  symptoms  of,  472 
Subluxation  of  cartilages  in   traumatic  ar- 
thritis, 453 
of  radius,  479 
Submaxillary  gland,  salivary,  solid  tumors 
of,  125,  179 
solid  tumors  of,  179 
region,  infection  in,  158 
Subperiosteal  fractures,  441 
Subphrenic  abscess,  253 

differential  diagnosis,  254 
left,  in  ulcer  of  stomach,  334 
Subungual  infection  complicating  wounds, 

532 
Supernumerary  digits,  661 
Suppuration  as  early  sign  of  acute  abdominal 
affections,  246 

circumscribed,  of  rectum,  350 

in  abdominal  wall,  231 

in  carotid  sheath  space,  159 

in  sheath  of  recti  muscles  of  abdomen,  231 

intracranial,  following  injuries,  55 

mastoid,  intracranial  complications  of,  80 

metastatic,  of  kidney,  252 

middle  ear,  intracranial  complications,  80 

previsceral,  in  neck,  158 

retromuscular,   in   abdominal   wall,    231 

subdural,  56 
Suppurative  pericarditis,  217 

pylephlebitis,  249 
Supracondyloid  fracture  of  humerus,  474 
Supraorbital    nerves,    method    of    making 

pressure  on,  29 
Sweat  glands    of    extremities,    adenocarci- 
noma of,  557 
adenoma  of,  556 
of  face,  adenoma  of,  99 
Swelling  in  tuberculosis  of  joints,  612 

in  tuberculous  coxitis,  636 
gonitis,  642 
Symmetrical  disease  of  lachrymal  and  sali- 
vary glands,  98 
Syndactylism,  661 

Synovitis,  chronic  serous,  605,  614  . 
Syphilis,  acquired,  of  bones  of  extremities, 
586 

leukocytosis  in,  728 

nasal  deformity  due  to,  98 

of  bladder,  cystoscopy  in,  744 

of  bones  of  extremities,  584,  585 
of  thorax,  205 

of  face,  96 


Syphilis  of  jaws,  120 

of  liver,  296 

of  mouth,  124 

of  salivary  glands,  141 

of  skull,  69 

of  testicle,  398 

of  tongue,  130 

saddle-nose  due  to,  97 

tertiary,  ulcerations  on  back  in,  201 
Syphilitic  arthritis,  619.     See  also  Arthritis, 
syphilitic. 

atrophy  of  tongue,  133 

bursitis  of  extremities,  567 

lesions,  secondary,  of  tongue,  131 
tertiary,  of  tongue,  131 

lymph-node  enlargement  of  neck,  168 

myositis,  of  extremities,  571 

pseudoparalysis,  585 

ulcerations  of  lip,  105 

ulcers  of  extremities,  545 
Syringomyelia,  arthritis  due  to,  624 

Tabes,  arthritis  due  to,  622 
Talipes  calcaneus,  657 
cavus,  657 
equinovarus,  656 
equinus,  656 
valgus,  657 
Tarsal  bones,  fractures  of,  519 
Teeth,  infection  of  jaws  from,  118 
Temperature  in  appendicitis,  259 

in  tuberculosis  of  joints,  613 
Temporo-maxillary  joint,  ankylosis  of,   122 
chronic  arthritis  of,  122 
diseases  of,  122 
primary  acute  arthritis  of,  122 
secondary  acute  arthritis  of,  122 
Temporo-sphenoidal  abscess,  83 
Tenderness  in  appendicitis,  257 
in  gallstone  colic,  264 
in  tuberculosis  of  joints,  612 
Tendons    and    muscles    of    forearm     and 
arm,  infection    between,    complicating 
wounds,  532 
dislocations  of,  427 
injuries  of,  424 

of  extremities,  diseases  of,  567 
inflammatory  affections  of,  567 
tumors  of,  570 
penetrating  wounds  of,  428 
rupture  of,  426 
Tendon-sheaths,     infection    along,    compli- 
cating wounds,  532 
injuries  of,  424 

of  extremities,  diseases  of,  567 
inflammatory  affections  of,  567 
tumors  of,  570 
penetrating  wounds  of,  428 
Tenesmus  in  intussusception,  282 
Tenosynovitis,   acute  primary,   of  extremi- 
ties, 567 
serofibrinous,  of  extremities,  567 
seropurulent,  of  extremities,  568 
secondary,  of  extremities,  568 
chronic,  of  extremities,  568 
serous,  of  extremities,  568 


INDEX. 


773 


Tenosynovitis,    chronic    syphilitic,    of    ex- 
tremities, 570 
crepitans,  of  extremities,  567 
of  extremities,  567 
tuberculous,  of  extremities,    568 
Tenovaginitis  of  extremities,  567.     See  also 

Tenosynovitis. 
Tenth  nerve,  injury,  in  fracture  of  base  of 

skull,  31 
Teratoma,  sacrococcygeal,  695 
Test,  phloridzin,  748 

tuberculin,  in  tuberculosis  of  joints,  613 
two-glass,  for  pus  in  genito-urinary  tract, 
381 
Testicle,  387 

abnormalities  in  development  of,  387 

benign  adenocystoma  of,  399 

ectopia  of,  388 

hernia  of,  in  connection  with  imperfect 

descent,  391 
hydrocele  of,  in  connection  with  imperfect 

descent,  391 
imperfect  descent  of,  388 
complications,  388 
hernia  and  hydrocele  in  connection 

with,  391 
inflammation  in,  389 
tumor  formation  in,  390 
inflammation  of,  in  imperfect  descent,  389 
mixed  tumors  of,  400 
neoplasms  of,  399 
retained,  388 
syphilis  of,  398 
traumatic  affections  of,  393 
tuberculosis  of,  393 
tumor  formation  of,  in  imperfect  descent, 

391 

tumors  of,  399 

Tetanus,  122,  540 

cephalic,  541 

complicating  wounds,  540 
differential  diagnosis,  541 
head,  541 

hydrophobicus,  541 
symptomatic,  122 
T-fractures  of  lower  end  of  humerus,  474 
Third  nerve,  injury,  in  fracture  of  base  of 

skull,  30 
Thoma-Zeiss  blood-counting  apparatus,  716 
Thoracic  aneurysm,  207 

conditions,  referred  pain  from,  276 
duct,  injuries  of,  155 

subcutaneous  injuries  of,  198 
viscera,  injuries  of,  195 

non-penetrating  or  subcutaneous  inju- 
ries of,  195 
wall,  actinomycosis  of,  202 

acute  and  chronic  inflammatory  pro- 
cesses of,  201 
phlegmon  of,  201 
skin  and  subcutaneous  tissues  of,  in- 
flammatory processes,  201 
tumors  of,  206 
Thorax,  193 

bones  of,  syphilis,  205 
bony,  affections  of,  202 


Thorax,  bony  walls  of,  injuries,  193 
fibroma  of,  206 
lipoma  of,  206 
penetrating  injuries  of,  199 

dyspnea  and  cyanosis  in,  200 
emphysema  in,  200 
empyema  in,  200 
hemothorax  in,  199 
pneumonia  in,  200 
pneumothorax  in,  199 
prolapse  of  lung  in,  200 
pigmented  moles  of,  206 
sarcoma  of,  206 
Throat,  cut-,  156 

Thrombophlebitis  of  extremities,  562 
Thrombosis  in  fractures,  442 
of  cavernous  sinus,  85 
of  cranial  sinus,  84 
of  extremities,  561 
of  mesenteric  vessels,  272 

differential  diagnosis,  273 
of  sigmoid  sinus,  85 
postoperative,  710 
sinus,  intracranial,  59 
Thyroglossal  cysts,  126,  176 

fistula,  147 
Thyrohyoid  bursae,  177 
Thyroid  adenoma,  186 

gland,  accessory,  cysts  of,  177 
Thyroidism,  acute,  postoperative,  714 
Thyroiditis,  188 

Tibia,  fractures  of  lower  end,  514 
of  shaft,  510 
of  upper  end,  506 
Tibiotarsal  dislocations,  516 
Tissues,  air  in,  in  fracture  of  base  of  skull, 

^7.    .     . 
soft,  injuries  of,  422 
signs,  423 
Toes,  dislocations  of,  524 

phalanges  of,  fractures,  522 
Tongue,  127 

benign  tumors  of,  133 
carcinoma  of,  134 

differential  diagnosis,  135 
chancre  of,  130 
congenital  affections  of,  127 
decubital  ulcers  of,  128 
goiter  of,  137 
hemangioma  of,  133 
injuries  of,  128 
lipoma  of,  133 
lymphangioma  of,  134 
malignant  tumors  of,  134 
mucous  patches  on,  131 
papilloma  of,  134 
psoriasis  of,  129 
sarcoma  of,  134 
syphilis  of,  130 
syphilitic  atrophy  of,  133 

lesions  of,  secondary,  131 
tertiary,  131 
tonsil  of,  137 
tuberculosis  of,  130 
Tongue-tie,  127 
Tonsil,  lingual,  13S 


774 


INDEX. 


Torsion  of  pedicles  of  ovarian  and  uterine 
tumors,  273 
differential  diagnosis,  274 
of  spermatic  cord,  274 
Trachea,  foreign  bodies  in,  156 

fractures  of,  155 
Trigeminal  nerve,  injur)',  in  fracture  of  base 
of  skull,  31 
neuralgia,  loi 
Trismus,  122,  540.     See  also  Tetanus. 
Trochanter,  great,  fracture  of,  498 
Trophic  ulcers  of  extremities,  546 
Tropical  abscess,  248 

differential  diagnosis,  248 
Tuberculin  test  in  tuberculosis  of  joints,  613 
Tuberculosis,    ileocecal,    inflammatory    tu- 
mors of  intestine  from,  307 
leukocytosis  in,  727 
of  ankle-joint,  645 

differential  diagnosis,  645 
of  bladder,  374 

cystoscopy  in,  739 
of  bones  of  extremities,  582 
of  breast,  225 
of  elbow-joint,  628 
of  hip-joint,  632 

differential  diagnosis,  637 
history,  633 
inspection  in,  632,  633 
location  of  pain  in,  636 
measurements  in,  636 
palpation  in,  632,  634 
swelling  in,  636 
x-ray  examination  in,  637 
of  jaws,  119 
of  joints,  611 

differential  diagnosis,  613 
family  and  personal  history,  613 
fungous  form,  612 
loss  of  function  and  rigidity  in,  612 
onset  and  course,  612 
pain  in,  612 
position  of  limb  in,  612 
swelling  in,  612 
temperature  in,  613 
tenderness  in,  612 
tuberculin  test  in,  613 
;v-rays  in,  613 
of  kidney,  363 

cystoscopic  examination  in,  365 
increased  frequency  of  urination  in,  364 
pain  in,  365 

renal  enlargement  in,  365 
symptoms,  364 

general,  365     _      _ 
ureteral  catheterization  in,  365 
urinary  changes  in,  364 
of  knee-joint,  641 

abscess,  sinus  formation,  and  fever  in, 

643 
differential  diagnosis,  643 
heat  in,  642 
pain  in,  642 

rigidity,  atrophy,  and  deformity  in,  642 
swelling  in,  642 
tenderness  in,  642 
x-ray  examination  in,  643 


Tuberculosis  of  ribs,  203 
of  sacroiliac  joint,  630 
of  salivary  glands,  141 
of  shoulder-joint,  628 
of  skull,  69 
of  sternum,  203 
of  testicle,  393 
of  tongue,  130 
Tumor  albus,  642 
Tumors,  benign,  of  bones  of  extremities,  594 

connective-tissue,    of   salivary    glands, 
142 

of  breast,  227 

of  face,  98 

of  jaws,  108 

of  tongue,  133 
cystic,  behind  rectum,  695 

of  neck,  174 
due  to  chronic  pancreatitis,  299 
granulation-tissue,  of  jaws,  11 1 
inflammatory,  of  intestine,  307 

from  ileocecal  actinomycosis,  307 
tuberculosis,  307 
intestinal  obstruction  from,  282 

history  of,  282 
malignant,  of  breast,  228 

of  extremities,  556 
of  epithelial  type,  557 

of  face,  100 

of  jaws,  113 

of  kidney,  315.     See  also  Kidney,  mal- 
ignant tumors  of. 

of  liver,  296 

differential  diagnosis, 

of  scalp,  69 

of  tongue,  134 
mixed,  of  salivary  glands, 

of  testicle,  400 
of  abdomen,     285.     See    also  Abdomen, 

tumors  oj. 
of  abdominal  wall,  233 
of  bladder,  376 

wall,  cystoscopy  in,  742 
of  bones  of  extremities,  593 
of  brain,  75.     See  also  Brain,  tumors  of. 
of  breast,  227 

differential  diagnosis,  230 
of  cerebellum,  77 
of  chest  wall,  206 
of  epididymis,  399 
of  frontal  lobe,  76 
of  gallbladder,  297 

difl'erential  diagnosis,  298 
of  inside  of  cheeks,  127 
of  intestine,  307 
■     of  jaws,  108 
of  joints,  626 
of  kidney,  311 
of  liver,  291 
of  lungs,  217 
of  mediastinum,  219 
of  mesentery,  310 
of  middle  fossa  of  skull,  78 
of  motor  region  of  brain,  76 
of  muscles  of  extremities,  572 
of  neck,  172.     See  also  A'ec/c,  tumors  of. 
of  nerves  of  extremities,  574 


297 


143 


INDEX. 


775 


Tumors  of  occipital  lobe,  77 
of  omentum,  310 
of  ovary,  large,  324 
pedunculated,  324 
torsion  of  pedicles,  273 

differential  diagnosis,  274 
of  palate,  127 
of  pancreas,  303 

differential  diagnosis,  303 
of  parietal  lobe,  77 
of  parotid  gland,  145 
of  peritoneum,  310 

of  pituitary  body  causing  acromegaly,  79 
of  pleura,  212 

of  pontomedullocerebellar  space,  77 
of  salivary  glands,  141,  142 
of  scalp,  66 

of  skin  and  subcutaneous  tissue  of  ex- 
tremities, 555 
of  skull,  72 
of  spinal  cord,  692 
of  spine,  692 
of  spleen,  304 
of  stomach,  289 

differential  diagnosis,  290 
of  tendons  of  extremities,  570 
of  tendon-sheaths  of  extremities,  570 
of  testicle,  399 
of  umbUicus,  236 
of  uterus,  pedunculated,  324 
torsion  of  pedicles,  273 

differential  diagnosis,  274 
pancreatic,  299 
sacrococcygeal,  695 
secondary,  of  ribs  or  sternum,  207 
solid,  of  neck,  178 

of  submaxillary    salivary    gland,    125, 
179 
vascular,  of  scalp,  68 
Twelfth  nerve,  injury,  in  fracture  of  base  of 

skull,  31 
Two-glass   test   for   pus   in   genito-urinary 

tract,  381 
Tympanites  in  enterostenosis,  342 

in  injuries  of  alimentary  canal,  241 
Typhoid  fever,  leukocytosis  in,  720 
perforation,  268 

differential  diagnosis,  269 
spine,  692 
Typhoidal  arthritis,  608 

Ulcer,  blastomycotic,  of  extremities,  546 

cystitic,  cystoscopy  in,  739 

decubital,  of  extremities,  548 
of  tongue,  128 

dental,  128 

duodenal,  332.     See  also  Ulcer  0}  stom- 
ach. 

of  bladder,  cystoscopy  in,  739 

of  stomach,  332 
complications,  333 
differential  diagnosis,  333 
dyspeptic  symptoms  in,  333 
hemorrhage  in,  333 
hour-glass  stomach  in,  334 
left  subphrenic  abscess  in,  334 
leukocytosis  in,  723 


Ulcer  of  stomach,  nausea  in,  333 
pain  in,  332 
perforation  in,  333 
perigastric  adhesions  in,  335 
symptoms,  332 
vomiting  in,  333 
perforating,  of  duodenum,  266 
differential  diagnosis,  267 
dullness    in    flanks    and    right    iliac 

region  in,  267 
muscular  rigidity  in,  266 
obliteration  of  liver  dullness  in,  266 
pain  in,  266 
pulse  in,  267 
symptoms,  266 
vomiting  in,  266 
of  stomach,  266 

differential  diagnosis,  267 

dullness    in    flanks    and    right    iliac 

region  in,  267 
muscular  rigidity  in,  266 
obliteration  of  liver  dullness  in,   266 
pain  in,  266 
pulse  in,  267 
symptoms,  266 
vomiting  in,  266 
of  typhoid  fever,  268 

dift'erential  diagnosis,  269 
rodent,  of  extremities,  557 
syphilitic,  of  extremities,  545 
traumatic,  of  extremities,  544 
trophic,  of  extremities,  546 
tuberculous,  of  extremities,  547 
varicose,  of  leg,  545 
Ulceration  of  lip,  105 

of  rectum,  non-malignant,  354 
on  back  in  tertiary  syphilis,  201 
Ulcerative  stomatitis,  123 
Ulna  and  radius,  dislocation  of,  477 
backward,  477 
fracture  of  shaft,  479 
of  upper  end,  477 
greenstick  fracture  of,  480 
lesions  of,  473 
Ulnar  nerve,  injury  of,  437 
Umbilical  hernia,   417.     See  also  Hernia, 

umbilical. 
Umbilicus,  abscess  discharging  through,  256 

tumors  of,  236 
Ungual  infection  complicating  wounds,  532 
Urachus,  malformations  in  connection  with, 
236 
patent,  cystoscopy  in,  744 
Ureter,  examination  of,  in  renal  calculus, 

.370 
with  sounds,  732 
patulency  of,  734 
stricture  of,  734 
Ureteral  catheterization,  732 

in  tuberculosis  of  kidney,  365 
concretions,  735 
Ureter-cystoscope,  Brenner's,  737 
Urethra,  congenital  malformations  of,  379 
contusion  of,  380 
diseases  and  injuries  of,  379 
rupture  of,  380 

in  fractures  of  pelvis,  490 


776 


INDEX. 


Urethroscopy    for    localization    of    pus    in 

genito-urinary  tract,  384 
Urinary  changes  in  renal  calculus,  367 
in  tuberculosis  of  kidney,  364 
organs,  injuries  of,  symptoms,  241 
system,  diseases  of,  leukocytosis  in,  724 
Urine,  crj^oscopy  of,  747 
electric  conductivity  of,  748 
examination  of,  732 

in  renal  and  vesical  lesions,  361 
in  acute  cystitis,  373 
Urosepsis,  251,  373 
Uterus,  myoma  of,  large,  324 
tumor  of,  pedunculated,  324 
torsion  of  pedicle,  273 

differential  diagnosis,  274 

Varicose  ulcers  of  leg,  545 
veins  of  extremities,  562 
complications,  563 
Vas  deferens,  inflammation  of  intra-abdom- 
inal portion,  276 
Veins,  injuries  of,  432 

of  extremities,  diseases  of,  561 
of  neck,  injuries  of,  154 
varicose,  of  extremities,  562 
complications,  563 
Ventral  hernia,  420 
Vermiform  appendix,  hernia  of,  in  inguinal 

hernia,  409 
Vertebrffi,  dislocations  of,  679 
pathology,  664 
fractures  of,  676.     See  also  Fractures  of 

spine. 
lumbar,  fractures  of,  678 
Vertebral  arteries,  injuries  of,  hemorrhage 
from,  50 
artery,  injury  of,  152 
Vertigo  in  brain  tumors,  76 
Viscera,  abdominal,  injuries  of,  237.     See 
also  Abdominal  viscera,  injuries  of. 
thoracic,  injuries  of,  194 

non-penetrating    or    subcutaneous    in- 
juries of,  195 
Visceral  crises,  274 
Visual  aphasia,  48 
Volvulus,  280 

constipation  in,  280 
examination  of  abdomen  in,  280 
nausea  in,  280 
pain  in,  280 
previous  histor}%  280 
shock  in,  280 
vomiting  in,  280 
Vomiting  after  operation,  70 

accompanying  symptoms,  705 
character  of  vomitus,  705 
length  of  time,  704 
in  appendicitis,  257 
in  cancer  of  stomach,  335 
in  gallstone  colic,  264 
in  injuries  of  alimentary  canal,  240 
in  intestinal  obstruction,  278 

strangulation,  280 
in  intussusception,  282 
in  perforating  ulcers  of  stomach  and  duo- 
denum, 266 


Vomiting  in  tumors  of  brain,  75 

in  ulcer  of  stomach,  333 

in  volvulus,  280 
Vomitus,    character    of,    in    postoperative 

vomiting,  705 
von    Graefe's    symptom    in    exophthalmic 

goiter,  189 

Wandering  spleen,  304 
Warts  of  scalp,  68 

papillar}',  on  extremities,  556 
Webbed  fingers,  661 
White  matter  of  brain,  lesions,  47 
Woody  phlegmon  of  neck,  161 
Word-deafness,  48 
Wounds,  anthrax  complicating,  543 
edema  complicating,  543 

cellulitis  of  finger  or  hand  complicating, 

531 

contused,  of  scalp,  18 

in  infants  and  3'oung  children,   18 
in  older  children  and  adults,  20 

emphysematous    cellulitis    complicating, 

534 
epidermal  infection  complicating,  531 
erj'sipelas  complicating,  535 
erysipeloid  complicating,  536 
glanders  complicating,  543 
gunshot,  of  spine,  684 
hydrophobia  complicating,  542 
infection   along    tendon-sheaths    compli- 
cating, 532 

between  muscles  and  tendons  of  fore- 
arm and  arm  complicating,  532 

in  lower  extremities  complicating,  534 

of  cutaneous  and  subcutaneous  tissues 
complicating,  531 
infective  complications  of,  529 
lockjaw  complicating,  540 
malignant  edema  complicating,  534 
of  bladder,  372 
of  Steno's  duct,  86 
of  upper  extremities,  local  infections  in, 

530 
penetrating,  of  muscles,  428 

of  scalp,  17 
of  tendons,  428 
of  tendon-sheaths,  428 
pyemia  complicating,  538 

differential  diagnosis,  540 
sapremia  complicating,  536 
septicemia  complicating,  537 

differential  diagnosis,  540 
septicopyemia   complicating,  538 
stab,'  of  spine,  6S4 

subungual  infection   complicating,  532 
tetanus  complicating,  540 
ungual  infection  complicating,  532  ^ 

Wrist,  dislocations  of,  484 

ganglion  of,  570 
Wrist-drop,  436 
Wrist-joint,  diseases  of,  629 
injuries  in  vicinity  of,  480 
Wry-neck,  150 

Y-FRACTURES  of  lower  end  of  humerus,  474 


SAUNDERS'  BOOKS 


on 


Nervous  and  Mental 
Diseases,  Children, 
Hygiene,  Nursing,  and 
Medical  Jurisprudence 

W.  B.  SAUNDERS   COMPANY 

925  WALNUT  STREET  PHILADELPHIA 

9.  HENRIETTA  STREET         COVENT  GARDEN,  LONDON 

THE  SUPERIORITY  OF  SAUNDERS'  TEXT=BOOK 

In  a  recent  series  of  articles  entitled 

"WHAT  ARE  THE  BEST  MEDICAL  TEXT-BOOKS?" 

a  well  known  medical  journal  compiled  a  tabulation  of  the 
text-books  recommended  in  those  schools  which  are  members 
of  the  American  Association  of  Medical  Colleges.  The  text- 
books were  divided  into  twenty  (20)  subjects  and  under  each 
subject  was  given  a  list  of  the  various  books  with  the  number 
of  times  each  book  is  recommended.  Saunders'  books  head 
ten  (10)  of  the  twenty  (20)  subjects,  the  largest  number  head- 
ed by  any  other  publisher  being  three  (3).  In  other  words, 
Saunders'  books  lead  in  as  many  subjects  as  the  books  of  all  the  other 
publishers  combined. 

A  Complete  Catalogue  of  Our  Publications  will  be  Sent  upon  request 

NOTICE 

The  prices  of  all  books  bound  in  sheep  or  half 
morocco  have  been  advanced  FIFTY  CENTS  PER 
VOLUME  over  the  prices  herein  listed. 


SAUNDERS'    BOOKS   ON 


Peterson  and  Haines' 
Le^al  Medicine  &  Toxicology 


A  Text=Book  of  Legal  Medicine  and  Toxicology.  Edited  by 
Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Pyschiatry,  College 
of  Physicians  and  Surgeons,  New  York ;  and  Walter  S.  Haines, 
M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Two 
imperial  octavo  volumes  of  about  750  pages  each,  fully  illustrated. 
Per  volume:  Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  ;^6.oo  net. 
Sold  by  Subscription. 

IN  TWO   VOLUMES— BOTH  VOLUMES  NOW   READY 

The  object  of  the  present  work  is  to  give  to  the  medical  and  legal  professions 
a  comprehensive  survey  of  forensic  medicine  and  toxicology  in  moderate  compass. 
This,  it  is  believed,  has  not  been  done  in  any  other  recent  work  in  English.  Under 
' '  Expert  Evidence ' '  not  only  is  advice  given  to  medical  experts,  but  suggestions 
are  also  made  to  attorneys  as  to  the  best  methods  of  obtaining  the  desired  infor- 
mation from  the  witness.  An  interestmg  and  important  chapter  is  that  on  ' '  The 
Destruction  and  Attempted  Destruction  of  the  Human  Body  by  Fire  and  Chemi- 
cals. ' '  A  chapter  not  usually  found  m  works  on  legal  medicine  is  that  on  ' '  The 
Medicolegal  Relations  of  the  X-Rays."  This  section  will  be  found  of  unusual  im- 
portance. The  responsibility  of  pharmacists  in  the  compounding  of  prescriptions, 
in  the  selling  of  poisons,  in  substituting  drugs  other  than  those  prescribed,  etc., 
furnishes  a  chapter  of  the  greatest  interest  to  every  one  concerned  with  questions 
of  medical  jurisprudence.  Also  mcluded  in  the  work  is  the  enumeration  of  the 
laws  of  the  various  states  relating  to  the  commitment  and  retention  of  the  insane. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  News,  New  York 

"  It  not  only  fills  a  need  from  the  standpoint  of  timeliness,  but  it  also  sets  a  standard  of 
what  a  text-book  on  Legal  Medicine  and  Toxicology  should  be." 

Columbia  Law  Review 

"  For  practitioners  in  criminal  law  and  for  those  in  medicine  who  are  called  upon  to  give 
court  testimony  in  all  its  various  forms  ...  it  is  extremely  valuable." 

Pennsylvania  Medical  Journal 

"  If  the  excellence  of  this  volume  is  equaled  by  the  second,  the  work  will  easily  take  rank 
as  the  standard  text-book  on  Legal  Medicine  and  Toxicology." 


NERVOUS  AND   MENTAL   DISEASES. 


Church  and  Peterson's 
Nervous  and  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Medical  Jurisprudence, 
Northwestern  University  Medical  School,  Chicago ;  and  Frederick 
Peterson,  M.D.,  President  New  York  State  Commission  on  Lunacy; 
Clinical  Professor  of  Neurology  and  Psychiatry,  College  of  Physicians 
and  Surgeons,  N.  Y.  Handsome  octavo,  937  pages  ;  341  illustrations. 
Cloth,  ;^5.0o  net ;  Sheep  or  Half  Morocco,  ;^6.oo  net. 

JUST  ISSUED— NEW   (5th)    EDITION 

This  work  has  met  with  a  most  favorable  reception  from  the  profession  at 
large.  It  fills  a  distinct  want  in  medical  literature,  and  is  unique  in  that  it 
furnishes  in  one  volume  practical  treatises  on  the  two  great  subjects  of  neurology 
and  psychiatry.  In  preparing  this  edition  Ur.  Church  has  carefully  revised  his 
entire  section,  placing  it  in  accord  with  the  most  recent  psychiatric  advances. 
In  Dr.  Peterson's  section  —  Mental  Diseases  —  the  Krsepelin  classification  of 
insanity  has  been  added  to  the  chapter  on  classifications  for  purposes  of  reference, 
and  new  chapters  on  Manio-Depressive  Insanity  and  on  Dementia  Precox  in- 
cluded. While  the  changes  throughout  have  been  many,  they  have  been  so 
made  as  but  slightly  to  increase  the  size  of  the  work. 


OPINIONS  OF  THE    MEDICAL   PRESS 


American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  really 
is  two  books-.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 

Journal  of  Nervous  and  Mental  Diseases 

"The  best  te.\t-book  exposition  of  this  subject  of  our  day  for  the  busy  practitioner.  .  .  , 
The  chapter  on  idiocy  and  imbecility  is  undoubtedly  the  best  that  has  been  given  us  in  any 
work  of  recent  date  upon  mental  diseases.-  The  photographic  illustrations  of  this  part  of  Dr. 
Peterson's  work  leave  nothing  to  be  desired." 

New  York  Medical  Journal 

"To  be  clear,  brief,  and  thorough,  and  at  the  same  time  authoritative,  are  merits  that 
ensure  popularity.  The  medical  student  and  practitioner  will  find  in  this  volume  a  ready  and 
reliable  resource." 


SAUNDERS'    BOOKS    ON 


Friihwald  and  WestcottV 
iseases    of  Children 


Diseases  of  Children.  A  Practical  Reference  Book  for  Students 
and  Practitioners.  By  Professor  Dr.  Ferdinand  Frlthwald,  of 
Vienna.  Edited,  with  additions,  by  Thompson  S  Westcott,  M.  D., 
Associate  in  Diseases  of  Children,  University  of  Pennsylvania.  Octavo 
volume  of  533  pages,  containing  176  illustrations.         Cloth,  $df.SO  net. 

JUST   READY 

This  work  represents  the  author' s  twenty  years'  experience,  and  is  intended 
as  a  practical  reference  work  for  the  student  and  practitioner.  With  this  refer- 
ence feature  in  view,  the  individual  diseases  have  been  arranged  alphabetically. 
The  prophylactic,  therapeutic,  and  dietetic  treatments  are  elaborately  discussed. 
The  practical  value  of  the  book  has  been  considerably  enhanced  by  the  many 
excellent  illustrations. 
E.  H.  Bartley.   M.  D,. 

Professor  of  Pediatrics,  Chemistry ,  and  Toxicology,  Long  Island  College  Hospital,  New  York. 
"It  is  a  new  idea,  which  ought  to  become  popular  because  of  the  alphabetic  arrangement. 
Its  title  expresses  just  what  it  is — a  ready  reference  hand-book." 


RuhrahV 
Diseases  of  Children 


A  Manual  of  Diseases  of  Children.      By   John    Ruhrah,   M.  D., 

Clinical  Professor  of  Diseases  of  Children,  College  of  Physicians  and 

Surgeons,  Baltimore.      i2mo  of  404  pages,  fully  illustrated.     Flexible 

leather,  ;^2.00  net. 

JUST  READY 

In  writing  this  manual  Dr.  Ruhrah' s  aim  was  to  present  a  work  that  would  be 
of  the  greatest  value  to  students.  All  the  important  facts  are  given  concisely  and 
explicitly,  the  therapeutics  of  infancy  and  childhood  being  outlined  very  care- 
fully and  clearly.  There  are  also  directions  for  dosage  and  prescribing,  and  a 
number  of  useful  prescriptions  are  included.  The  feeding  of  infants  is  given  in 
detail,  and  the  entire  work  is  amply  illustrated  with  practical  illustrations.  A 
valuable  aid  consists  in  the  inany  references  to  pediatric  literature,  so  selected 
as  to  be  easily  accessible  by  the  student. 


INSANITY  AND   HYGIENE. 


Brower  and  Bannister 
on  Insanity 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General 
Practitioner.  By  Daniel  R.  Brower,  A.M.,  M.D.,  LL.  D.,  Professor 
of  Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  affiliation 
with  the  University  of  Chicago  ;  and  Henry  M.  Bannister,  A.  M., 
M.  D.,  formerly  Senior  Assistant  Physician,  Illinois  P2astern  Plospital 
for  the  Insane.  Handsome  octavo  of  426  pages,  with  a  number  of 
full-page  inserts.     Cloth,  ^^3.00  net. 

FOR   STUDENT  AND   PRACTITIONER 

This  work,  intended  for  the  student  and  general  practitioner,  is  an  inteUigible, 
up-to-date  exposition  of  the  leading  facts  of  psychiatry,  and  will  be  found  of  in- 
valuable service,  especially  to  the  busy  practitioner  unable  to  yield  the  time  for  a 
more  exhaustive  study.  The  work  has  been  rendered  more  practical  by  omitting 
elaborate  case  records  and  pathologic  details,  as  well  as  discussions  of  speculative 
and  controversial  questions. 

American  Medicine 

"  Commends  itself  for  lucid  expression  in  clear-cut  English,  so  essential  to  the  student  in 
any  department  of  medicine.  .  .  .  Treatment  is  one  of  the  best  features  of  the  book,  and  for 
this  aspect  is  especially  commended  to  general  practitioners." 

Bergey's  Hygiene 

The  Principles  of  Hygiene:  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  536  pages,  illustrated.     Cloth,  ^3.00  net. 

RECENTLY  ISSUED— SECOND  REVISED  EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physiciajis  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  vears. 
This  new  second  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 


SAUNDERS'    BOOKS    ON 


GET  A  •  THE  NEW 

THE  BEST  /\  m  C  r  1  C  8i  11  STANDARD 

Illustrated   Dictionary 

Just  Issued— The  New  (4th)  Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistiy,  and  kindred  branches  ;  with  over  lOO  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  8oo  pages,  bound  in  full  flexible  leather. 
Price,  ;^4.50  net;  with  thumb  index,  ;^5.oo  net. 

Gives  a  Mzkximum  Amount  of  Matter  in  a  Minimum  Space,  and  at  the  Lowest 

Possible  Cost 

WITH   2000  NEW  TERMS 

The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  1 3^ 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  two  thousand 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  loo  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University ,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren.  M.D„  LL.D.,  F.R.C.S.  (Hon.) 

Professor  of  Su7-gery,  Harvard  Medical  School. 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.      I  use  it  in  preference  to  any  other." 


PERSONAL   HYGIENE. 


Galbraith*s 
Four  Epochs  of  Woman's  Life 

Second  Revised  Edition— Recently  Issued 


The  Four  Epochs  of  Woman's  Life:  A  Study  in  Hygiene.  By 
Anna  M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of 
Medicine,  etc.  With  an  Introductory  Note  by  John  H.  Musser,  M.  D., 
Professor  of  Clinical  Medicine,  University  of  Pennsylvania.  i2mo 
volume  of  247  pages.     Cloth,  $1.50  net. 

MAIDENHOOD.  MARRIAGE,  MATERNITY.  MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive 
manner,  those  truths  of  which  every  woman  should  have  a  thorough  knowledge. 
Written,  as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped 
even  by  those  most  unfamihar  with  medical  subjects. 

Binning>ham  Medical  Review,  England 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome." 


Pyle*s  Personal  Hygiene 


A  Manual  of  Personal  Hygiene  :  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle,  A.  M., 
M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  441  pages,  fully  illustrated.     Cloth,  ;$i.50  net. 

NEW  (2d)  EDITION-RECENTLY  ISSUED 

The  object  of  this  manual  is  to  set  forth  plainly  the  best  means  of  developing 
and  maintaining  physical  and  mental  vigor.  It  represents  a  thorough  exposition 
of  living  upon  a  physiologic  basis.  In  this  new  second  edition  there  have  been 
added  new  chapters  on  Home  Gymnastics  and  Domestic  Hygiene,  besides  an 
Appendi-x;  of  Emergency  Procedures. 

Boston  Medical  and  Surgical  Journal 

■•  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers  have 
succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound  knpnti 
edge." 


SAUiXDERS'   BOOKS    OK 


Draper's  Legal  Medicine 

A  Text=Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper, 
A.  M.,  M.  D.,  Professor  of  Legal  Medicine  in  Harvard  University,  Bos- 
ton ;  Medical  Examiner  of  the  County  of  Suffolk,  Massachusetts,  etc. 
Handsome  octavo  volume  of  573  pages,  fully  illus.     Cloth,  $4.00  net. 

A  NEW  WORK— RECENTLY  ISSUED 

The  subject  of  Legal  Medicine  is  one  of  great  importance,  especially  to  the 
general  practitioner,  for  it  is  to  him  that  calls  to  attend  cases  which  mav  prove  to 
be  medicolegal  in  character  most  frequently  come.  The  medicolegal  field  includes 
not  only  deaths  of  a  homicidal  nature,  but  also  suits  at  law — the  fatal  railway  acci- 
dent, machinery  casualties,  and  the  like,  to  which  the  neighboring  physician  may 
be  called,  and  later,  perhaps,  summoned  to  court.  It  is  evident,  therefore,  that 
every  practitioner  should  be  thoroughly  versed  in  all  branches  of  medicolegal 
science.  This  volume,  although  prepared  as  a  help  to  medical  students,  will  be 
found  no  less  valuable  and  instructive  to  practitioners.  The  author  has  had 
twenty-six  years'  experience  as  Medical  Examiner  for  the  city  of  Boston,  his  in- 
vestigations comprising  nearly  eight  thousand  deaths  under  a  suspicion  of  violence. 

Hon.  Olin  Bryan.  LL.  B. 

Professor  of  Medical  Jurisprudence,    Baltimore  Medical  College 

"  A  careful  reading  of  Draper's  Legal  Medicine  convinces  me  of  the  excellent  character  of 
the  work.  It  is  comprehensive,  thorough,  and  must,  of  a  necessity,  prove  a  splendid  acquisition 
to  the  libraries  of  those  who  are  interested  in  medical  jurisprudence." 

Jakob  and  FisherV 

Nervous  System  and  its  Diseases 

Atlas  and  Epitome  of   the  Nervous    System   and  Its  Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Fnvn  the  Second  Revised 
German  Edition.  Edited,  with  additions,  by  Edward  D.  Fisher,  M.  D., 
Professor  of  Diseases  of  the  Nervous  System,  Universit}-  and  Bellevue 
Hospital  [Medical  College,  New  York.  With  83  plates  and  copious  text. 
Cloth,  S3. 50  net.     In  Saunders'  Hand-Atlas  Series. 

The  matter  is  divided  into  Anatomy,  Pathology,  and  Description  of  Diseases 
of  the  Nervous  System.  The  plates  illustrate  these  divisions  most  completely  ; 
especially  is  this  so  in  regard  to  pathology.  The  exact  site  and  character  of  the 
lesion  are  portrayed  in  such  a  way  that  they  cannot  fail  to  impress  themselves  on 
the  memory  of  the  reader. 

Philadelphia  Medical  Journal 

"  We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  sciendfic  fidelity  of  this  hand-atlas." 


DISEASES   OF  CHILDREN. 


KerrV  Diagnostics  qf 
Diseases   qf  Children 

Diagnostics  of  the  Diseases  of  Children.  By  LeGrand  Kerr, 
M.D.,  Professor  of  Diseases  of  Children,  Brooklyn  Postgraduate  Med- 
ical School,  Brooklyn.     Octavo  of  550  pages,  fully  illustrated. 

JUST   READY 

Dr.  Kerr's  work  differs  from  all  others  on  the  diagnosis  of  diseases  of  children 
in  that  the  objective  syjnptotns  are  particularly  emphasized.  The  author  believes 
that  as  the  objective  symptoms  are  the  main  sources  of  information  in  diagnosing 
children's  diseases,  the  subject  should  be  discussed  with  these  symptoms  as  the 
foundation.  The  constant  aim  throughout  has  been  to  render  a  correct  diagnosis 
as  early  in  the  course  of  the  disease  as  possible,  and  for  this  reason  differential 
diagnosis  is  presented  from  the  very  earliest  symptoms.  The  sequelae  of  the 
various  diseases  have  been  considered  only  to  the  extent  that  they  may  be  of  value 
in  anticipating  them  and  thus  aiding  in  their  early  diagnosis.  The  physician  will 
find  the  many  original  illustrations  a  source  of  much  information  and  help. 


PAUL'S  FEVER   NURSING  just  issued 

Nursing  in  the  Acute  Infectious  Fevers.  By  George  P.  Paul,  M.D., 
Assistant  Visiting  Physician  to  the  Samaritan  Hospital,  Troy,  N.  Y.  i2mo  of  200 
pages.      Cloth,  $1.00  net. 

"  The  book  is  an  excellent  one  and  will  be  of  value  to  those  for  whom  it  is  intended.  It  is  well 
arranged,  the  text  is  clear  and  full,  and  the  illustrations  are  good." — The  London  Lancet. 

PAUL'S  MATERIA  MEDICA  for  NURSES       Just  issued 

Materia  Medica  for  Nurses.  By  George  P.  Paul,  M.  D.,  Assistant  Visiting 
Physician  to  the  Samaritan  Hospital,  Troy.      l2mo  of  240  pages.      Cloth,  $1.50  net. 

Dr.  Paul  arranges  the  physiologic  actions  of  the  drugs  according  to  the  action  of  the  drug  and  not 
the  organ  acted  upon.     An  important  section  is  that  on  pretoxic  signs. 

AMERICAN  TEXT-BOOK  qf  DISEASES 

qf    CHILDREN  second  Edition 

American  Text-Book  of  Diseases  of  Ciiii.nREN.  Edited  by  Louis  Starr, 
M.D.,  assisted  by  Thompson  S.  Westcott,  M.D.  Octavo,  1244  pages,  profusely 
illustrated.     Cloth,  ^7.00  net ;   Half  Morocco,  $8.00  net. 


SAUNDERS'  BOOKS  ON 


Friedenwald  £f  Ruhrah*s 
Dietetics  for  Nurses 


Dietetics  for  Nurses.  By  Julius  Friedenwald,  M.  D.,  Clinical 
Professor  of  Diseases  of  the  Stomach,  College  of  Physicians  and  Sur- 
geons, Baltimore ;  and  John  Ruhrah,  M.  D.,  Clinical  Professor  of 
Diseases  of  Children,  College  of  Physicians  and  Surgeons,  Baltimore. 
i2mo  of  363  pages.     Cloth,  $1.50  net. 

JUST   ISSUED 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse,  both  in  the 
training  school  and  after  graduation.  It  aims  to  give  the  essentials  of  dietetics, 
considering  briefly  the  physiology  of  digestion  and  the  various  classes  of  foods 
and  the  part  they  play  in  nutrition.  The  subjects  of  infant  feeding  and  the  feeding 
of  the  sick  are  fully  discussed,  and  rectal  alimentation  and  the  feeding  of  oper- 
ative cases  are  fully  described.  Diet-lists  and  recipes  for  the  invalid's  dietary 
are  appended. 

Edinburg  Medical  Journal 

"It    appears   to    us    to    contain    all   the    practical  side   of  dietetics,   of  handy  size  and   de- 
void of  padding." 


Lewis*   Anatomy   and 
Physiology  for  Nurses 

Anatomy  and  Pliysiology  for  Nurses.      By  LeRoy  Lewis,  M.  D., 
Surgeon  to  and  Lecturer  on  Anatomy  and   Physiology  for  Nurses  at 
the  Lewis   Hospital,  Bay  City,  Michigan.      i2mo   of  317   pages,  with 
146  illustrations.     Cloth,  $\.']^  net. 

JUST   ISSUED 

The  author  has  based  the  plan  and  scope  of  the  work  on  the  methods  he  has 
employed  in  teaching  the  subjects,  and  has  made  the  text  unusually  simple  and 
clear.  The  text  is  rendered  more  comprehensive  by  the  practical  illustrations, 
representing  the  best  that  could  be  obtained. 

Nurses  Journal  of  the  Pacific  Coast 

"  It  is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects  in 
hand." 


NURSING. 


De  Lee's  Obstetrics  for  Nurses 

Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor 
of  Obstetrics  in  the  Northwestern  University  Medical  School;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  460  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

JUST   ISSUED— NEW(2nd) EDITION 

The  illustrations  in  Dr.  De  Lee's  work  are  nearly  all  original,  and  represent 
photographs  taken  from  actual  scenes.  The  text  is  the  result  of  the  author's  eight 
years'  experience  in  lecturing  to  the  nurses  of  five  difterent  training  schools. 

J.  Clifton  Edgar,  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery ,  Cornell  Medical  School,  N.  Y. 
"  It  is  far-and-away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Philadel- 
phia Polyclinic.      i2mo  of  400  pages,  illustrated.     Buckram,  $1.7 S  "et. 

RECENTLY  ISSUED— SECOND  REVISED  EDITION 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 

Reference   Handbook  for  Nurses 

A  Reference  Handbook  for  Nurses.  By  Amanda  K.  Beck,  of 
Chicago,  111.     32nio  of  177  pages.      Flexible  morocco,  ^^1.25  net 

RECENTLY  ISSUED 

This  little  book  contains  information  upon  every  question  that  comes  to  a 
nurse  in  her  daily  work,  and  embraces  all  the  information  that  she  requires  to 
carry  out  any  directions  given  by  the  physician. 

Boston  Medical  and  Surgical  Journal 

"Must   be   regarded   as  an   extremely  useful   book,  not  only  for  nurses,  but  for  physicians." 


SAUNDERS'    BOOKS   ON 


Hofmann  and  Peterson's 
Le£(al  Medicine 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna, 
Edited  by  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Psychi- 
atry in  the  College  of  Physicians  and  Surgeons,  New  York.  With  120 
colored  figures  on  56  plates  and  193  half-tone  illustrations.  Cloth, 
^3.50  net.     In  Saunders'  Hand-Atlas  Series. 

By  reason  of  the  wealth  of  illustrations  and  the  fidelity  of  the  colored  plates, 
the  book  supplements  all  the  text-books  on  the  subject.  Moreover,  it  furnishes  to 
every  physician,  student,  and  lawyer  a  veritable  treasure-house  of  information. 

The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection  with 
this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical  jurist  and  to 
the  student  of  forensic  medicine." 

Chapman's 
Medical  Jurisprudence 

Medical  Jurisprudence,  Insanity,  and  Toxicology.  By  Henry  C. 
Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical 
Jurisprudence  in  Jefferson  Medical  College,  Philadelphia.  Handsome 
i2mo  of  329  pages,  fully  illustrated.     Cloth,  ;$i.75  net. 

RECENTLY   ISSUED— THIRD   REVISED   EDITION.  ENLARGED 

This  work  is  based  on  the  author' s  practical  experience  as  coroner' s  physician 
of  the  city  of  Philadelphia  for  a  period  of  six  years.  Dr.  Chapman's  book, 
therefore,  is  of  unusual  value. 

This  third  edition  has  been  thoroughly  revised  and  greatly  enlarged,  so  as  to 
bring  it  absolutely  in  accord  with  the  very  latest  advances  in  this  important  branch 
of  medical  science.  There  is  no  doubt  it  will  meet  with  as  great  fa\-or  as  the 
previous  editions. 

Medical  Record,  New  York 

"The  manual  is  essentially  practical,  and  is  a  useful  guide  for  the  general  practitioner, 
besides  possessing  literary  merit." 


NURSING.  1 3 


Golebiewski  anc)  Bailey's 
Accident  Diseases 


Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed, 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, 
M.D.,  Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York. 
With  71  colored  illustrations  on  40  plates,  143  text-illustrations,  and 
549  pages  of  text.  Cloth,  34.00  net.  Li  Saunders'  Hand-Atlas 
Series. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereb)'  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is 
indispensable  to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to 
advanced  students,  to  surgeons,  and,  on  account  of  its  illustrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident-insurance  organizations. 

The  MediceJ  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  grow- 
ing in  extent  all  the  time.     The  pictorial  part  of  the  book  is  very  satisfactory." 

Stoney*s 
Materia  Medic  a  for  Nurses 


Practical  Materia  Medica  for  Nurses,  with  an  Appendix  containing 
Poisons  and  their  Antidotes,  with  Poison-Emergencies  ;  Mineral  Waters  ; 
Weights  and  Measures  ;  Dose-List,  and  a  Glossary  of  the  Terms  used 
in  Materia  Medica  and  Therapeutics.  By  Emily  M.  A.  Stonev,  of  the 
Carney  Hospital,  South  Boston.      i2mo  of  300 pages.     Cloth,  $1.50  net. 

RECENTLY  ISSUED— NEW  (3rd)  EDITION 

In  making  the  revision  for  this  new  third  edition,  all  the  newer  drugs  have 
been  introduced  and  fully  discussed.  The  consideration  of  the  drugs  includes 
their  sources  and  composition,  their  various  preparations,  physiologic  actions, 
directions  for  administering,  and  the  symptoms  and  treatment  of  poisoning. 

Journal  of  the  American  Medical  Association 

"  So  far  as  we  can  see,  it  contains  everything  that  a  nurse  ought  to  know  in  regard  to  drugs. 
As  a  reference-book  for  nurses  it  will  without  question  be  very  useful." 


14  SAUNDERS'    BOOKS    ON 


Stoney*s  Nursing' 


Practical  Points  in  Nursing:  for  Nurses  in  Private  Practice.  By 
Emily  M.  A.  Stoney,  Superintendent  of  the  Training  School  for  Nurses 
at  the  Carney  Hospital.  South  Boston,  Mass.  466  pages,  fully  illus- 
trated.    Cloth,  $1.7 S  net. 

THIRD   EDITION,  THOROUGHLY  REVISED— RECENTLY   ISSUED 

In  this  volume  the  author  explains  the  entire  range  of  private  nursing  as  dis- 
tinguished from  hospital  nursing,  and  the  nurse  is  instructed  how  best  to  meet  the 
various  emergencies  of  medical  and  surgical  cases  when  distant  from  medical  or 
surgical  aid  or  when  thrown  on  her  own  resources.  An  especially  valuable  feature 
\vill  be  found  in  the  directions  how  to  improvise  everything  ordinarily  needed  in  the 
sick-room. 

The  Lancet,  London 

"A  very  complete  exposition  of  practical  nursing  in  its  various  branches,  including  obstetric 
and  gynecologic  nursing.     The  instructions  given  are  full  of  useful  detail." 


Stoney 's  Technic  for  Nurses 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  M.  A. 
Stoney,  Superintendent  at  Carney  Hospital,  South  Boston.  Revised 
by  Frederic    R.    Griffith,  M.  D.,  Surgeon,  of  New   York.     i2mo, 

278  pages,  illustrated.      Cloth,  ;^i.50  net. 

RECENTLY  ISSUED— NEW  (2d)   EDITION 

Trzuned  Nurse  amd  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  during 
their  hospital  course  and  in  private  practice." 

Spratling  on  Epilepsy 

Epilepsy  and  Its  Treatment.      By  William   P.  Spratling,   M.  D., 

Medical  Superintendent   of  the   Craig  Colony  for  Epileptics,   Sonyea, 

New  York.     Octavo  of  522   pages,  fully  illustrated.      Cloth,  ^4.00  net. 

The  Lancet,  London 

"  Dr.  Spratling's  work  is  written  throughout  in  a  clear  and  readable  style.  .  .  .  The  work 
is  a  mine  of  information  on  the  whole  subject  of  epilepsy  and  its  treatment." 


CHILDREN  AND   HYGIExXE.  15 

Griffith*s  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Penn. ;  Physician  to  the 
Children's  Hospital,  Phila.    i2mo,  436  pp.   Illustrated.    Cloth,  ^1.50  net, 

RECENTLY   ISSUED— THIRD   EDITION,  THOROUGHLY   REVISED 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  in  the  hope  that  the  volume 
may  be  of  service  not  only  to  mothers  and  nurses,  but  also  to  students  and  practi- 
tioners whose  opportunities  for  observing  children  have  been  limited. 

New  York  Medical  Journal 

"  We  are  confident  if  this  little  work  could  find  its  way  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  vv^ould  be  lessened  by  at  least  fifty  per  cent." 

Crothers*  Morphinism 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  By  T.  D.  Crothers,  M.  D.,  Superintendent 
of  Walnut  Lodge  Hospital,  Hartford,  Conn.  Handsome  i2mo  of  351 
pages.     Cloth,  ^$2.00  net. 

The  Lancet,  London 

"An  excellent  account  of  the  various  causes,  symptoms,  and  stages  of  morphinism,  the 
discussion  being  throughout  illuminated  by  an  abundance  of  facts  of  clinical,  psychological,  and 
social  interest." 

Abbott's  Transmissible  Diseases 

The  Hygiene  of  Transmissible  Diseases :  Their  Causation,  Modes 
of  Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  ;$2.50  net. 

SECOND   REVISED    EDITION 

During  the  interval  that  has  elapsed  since  the  appearance  of  the  first  edition 
investigations  upon  the  modes  of  dissemination  of  certain  of  the  specific  infections 
have  been  very  active.  The  sections  on  Malaria,  Yellow  Fever,  Plague,  Filariasis, 
Dysentery,  and  Tuberculosis  have  been  both  revised  and  enlarged. 

The  Lancet,  London 

"  We  heartily  commend  the  book  as  a  concise  and  trustworthy  guide  in  the  subject  with 
which  it  deals,  and  we  sincerely  congratulate  Professor  Abbott." 


i6  SAUNDERS'   BOOKS  ON  CHILDREN. 

,  •jtx'j*  Fourth  Edition,  Revised 

American  Pocket  Dictionary  Recently  issued 

American  Pocket  jMedical  Dictionary.  Edited  by  W.  A.  New- 
man Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the 
Unive'rsity  of  Pennsylvania.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  just  Ready 

Immediate  Care  of  the  Injured.  B}-  Albert  S.  Morrow,  M.  D., 
Attending  Surgeon  to  the  New  York  City  Hospital  for  the  Aged  and 
Infirm.      Octavo  of  340  pages,  with  238  illustrations.     Cloth,  $2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  everv 
day  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.    Physicians  and  nurses  will  find  it  indispensible. 

POWeirS    Diseases     of    Children  Third  Edition,  Revised 

Essentials  of  the  Diseases  of  Children.  By  ^^'ILLIAM  M.  Powell, 
M.  D.  Revised  by  Alfred  Hand,  Jr.,  A.  B.,  M.  D.,  Dispensary- 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  31.00  net.  /;;  Saunders'' 
Question-  Compend  Series. 

Shaw  on  Nervous  Diseases  and  Insanity      PoSh^^Edltion 

Essentials  of  Nervous  Diseases  and  Insanity  :  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By'  the  late 
John  C.  Shaw,  M.  D.,  Chnical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  $1.00  net.  In  Saunders'  Question- Cof?i- 
pend  Series. 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted." 
— Boston  Medical  and  Surgical  Joiirfial. 

Starr's  Diets  for  Infants  and  Children 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By 
Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  INIaternity  Hospital, 
Philadelphia.  230  blanks  Tpocket-book  size).  Bound  in  flexible  Morocco, 
^1.25  net. 

Grafstrom's  Mechano-Therapy  seco^rRSd'clon 

A  Text-book  of  Mechano-therapy  (Massage  and  IMedical  Gymnas- 
tics). By  Axel  V.  Gr.a.fstrom,  B.  Sc,  M.  D.,  Attending  Physician  to 
the  Gustavus  Adolphus  Orphange,  Jamestown,  New  York.  i2mo,  200 
pages,  illustrated.     Cloth,  Si. 25  net. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 
j 

I 

1 

*%:■ 

fv 

'        ^"l-i 

( 

■•K 

C28(546)M25 

RD  °35^EI8^C  T^'^^  LIBRARIES  (hsl,stx) 

Surgical  r!),:ia;iijsis 


2002118203 


RP5^ 


6  A  5' 


I 


